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SAN JOAQUT--COUNTY ENVIRONMENTAL HEALT 7EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5� G Ci <br /> OWNER I OPERATOR n <br /> 5 law o asp 10 1l&X-CKI1B1IUUNG4DR 20 <br /> FAcuTY NAME 2 m 4- 95 ��u '1 Lf � I �'I e <br /> SIE ADS ni') I V 1 <br /> Streit Numf»r 4L.. I He MA zip coft <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number strwNam <br /> CITY STATE ZIP <br /> PHONE#i —� T• APN#/,�/ ` , LAND USE APPLICATION# / <br /> PHONE#2 E"T. BOS DISTRICT LOCATIONCODE <br /> C <br /> ( ) C <br /> CONTRACTO SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> BUSINESS N -l--t PHONE <br /> c7Tec-�j't� Jtc.� �J Y— <br /> HOME Q LWG AD _ Fax# 67'63 <br /> rLCx'( ) <br /> CITY STATF� ZIP C.t2 os— <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandaPATE and FEDERAL laws, <br /> AP <br /> 'C 'S j DATE: f (P--yx <br /> PROPERTY BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> JjAPPL/CdNT is not the BILLING PAR proojojauthorization to sign is required Title <br /> Ai1THORIZATION TO RELEASE INFORM TION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> infomlation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S /A 0 <br /> COMMENTS: R ECEI V ED <br /> JAN 0 4 2007 / <br /> SAN dOAQUIN COUNTY v Li <br /> ENVIRONMENTAL I ` I <br /> TMENi <br /> ACCEPTED BY: - EMPLOYEE#: DATE: 6 <br /> ASSIGNED T0: EMPLOYEE#: DATE: <br /> Date Service omp d (if already c mpieted): SERVICE CODE: b P 1 E: O <br /> Fee Amount: Ll Amount Pald ' 8 s Payment Date <br /> Payment Type R/ Invoice# Check# S Received By. <br /> EHD 48-02-025 '? <br /> REVISED 11/17/2003 <br />