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SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -A�'Ikte - 500 6 q 7 a 9 <br /> OWNER/OPERATOR,,-, <br /> ' CHECK If BILLING ADDRESS <br /> FACILITY NAME �`�.(L� "67j(,t <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ✓ <br /> i I y`7Z_ b 0 C-oc <br /> C C 1 �{ 'Street Number Street Name <br /> CLPY STATE /` ZIP 7 <br /> -A� <br /> ONE#1 EXT• APN# LAND USE APPLICATION# <br /> ONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> EQUESTOR 6 Y 1 ` V l.1 � ` i <br /> I o <br /> O A—I�t (c V i , CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex,,,1 T's - 1 C <br /> HOME Or MAILING ADDRESS _ FAX# C <br /> 14- CJ - 2 Z, - <br /> CITY L CrJ STATE C� ZIP �7 <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 DEPARTIVMNT 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,Stand ds,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNAT. DATE; `, 3 147-1 <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT C <br /> If APPLICANT is not the ILLINGPARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA 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 and at the same time it is <br /> provided to me or my representative. <br /> TY EQUESTED: <br /> V�L31 .-3. <br /> MPpPQOX ENoa tN <br /> CIN W'J%O PPA�M <br /> E p�- _ <br /> CEPTED BY: Cr t`�L-T L EMPLOYEE#: DATE: S l� <br /> ASSIGNED TO: <br /> ,'✓ V Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: cL PIE: D <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />