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SAN.JOAQUIN ''UNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �( W <br /> 5k-()(D 22,700,'� <br /> OWNER I OPERATOR <br /> 0, (-LA, CHECK if BILLING ADDRESS❑ <br /> FAP' <br /> N <br /> 9-k* <br /> Cor <br /> SITE ADDREQS <br /> qa ,Street Number Direction Street Name �o1 <br /> Cede <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 1 r <br /> RHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQiJESTUR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Exr• <br /> zs -7 <br /> HoME Or MAILING ADDRESS FAX# <br /> CITY T E ZI <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 Cortes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:— wss P'(Occ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 environmental/site assessment <br /> information to the SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. NT <br /> TYPE OF SERVICE REQUESTED: t, R CF_IV F <br /> COMMENTS: Z0 4 <br /> f EB % 3 l]]UU <br /> SAN JOaoU;N COUNTY <br /> �NVIRaNMENTaI_ <br /> 9EALTH DEPARTMENT <br /> ACCEPTED BY: L EMPLOYEE#: 31M DATE: 7- Z3 a <br /> ASSIGNED TO: L EMPLOYEE#: 350 DATE: 2/ ? a <br /> Date Service Completed (if already completed): SERVICE CODE: rn.� P I E: <br /> Fee Amount: �-� 1 Amount Paid "� Payment Date t-'r, © r✓ 1 <br /> Payment Type ✓'! Invoice# Check# -7 I' Received By: 4 .� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />