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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />g n C J A)-' P I-^ <br />FACILITY ID # <br />F�-- <br />SERVICE REQUEST # <br />S P coo 3S I'S2— <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />B? WFSi C -Ail <br />FACILITY NAME <br />A�t., AMIP� <br />HOME or MAILING ADDRESS <br />13Ciu w.t., PA Ss Q (3 <br />SITE AD�SS <br />v Street Number <br />Direction <br />` <br />Street Name <br />J1 c r T � . <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />( I <br />APN # <br />P 1 E: Z� C" <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( I <br />is P-1 I_ � <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�Ati T'1uit�+ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />F,�:���r� <br />PHONE # ExT' <br />►3 qq�� 39 ►2 <br />HOME or MAILING ADDRESS <br />13Ciu w.t., PA Ss Q (3 <br />FAX # <br />DATE: zZ Z7 U <br />( I <br />CITY CJ <br />STATE C.4 ZIP -1 qS�� <br />ti ( Z' ti a <br />DATE: Z <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE !>;E <br />laws. <br />APPLICANT'S SIGNATURE: C �� DATE: OJ �,�2 �� 9 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT t1(, C <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORNIATION: 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 and at the same time it is <br />provided to me or my representative. � ' 42W -f <br />TYPE OF SERVICE REQUESTED: u �T �� F t--/ <br />1 ECIVEu <br />COMMENTS: <br />Z004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HF,LTH DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE #: C)3 2 ( <br />DATE: zZ Z7 U <br />ASSIGNED TO: A T£ <br />EMPLOYEE #: { / <br />DATE: Z <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />(� r/ <br />P 1 E: Z� C" <br />Fee Amount:79 �i 5 , oL <br />Amount Paid <br />is P-1 I_ � <br />Payment Date O LI. <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />