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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro erty FACILITY ID# SERVICE REQUEST# <br /> a",eS,�' �)f� Oce--7 94,--D <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACIUTY NAME 60,Al <br /> SITE ADDRESS <br /> ` <br /> / 5� Street Number Directfon Street Name CI JZI/Code <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 /> (5-1o ) a2-!f�0a06 <br /> PHONE#2ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /I PHO E# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> / -'q <br /> CITY ( ) <br /> C L�/'� STATE ZIP 20- <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 <br /> or 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 rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar an EDE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ 6PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT S/11F1.Z6 /-/J/VAeey_ <br /> If APPLICANT is not the BILLING PARTY_proofofauthorization 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ansame same time it is <br /> provided to r.-.c or�..y representative. rY <br /> TYPE OF SERVICE REQUESTED: c90 Co -5 © <br /> COMMENTS: <br /> Ow(I Pte' i (D ,y "' °.aQ� <br /> �CDpMFh��N <br /> gRrM�T� <br /> ACCEPTED BY: SAJ r4 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: 0(0/ P/E: l 1 <br /> Fee Amount: �\��— Amount Paid �5�.�(� Payment Date <br /> Payment Type Invoice# Check# A)l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />