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SAN JOAQUIN '~OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> : SERVICE REQUEST <br /> Type of Bu ' ess or Prop y ^ FACILITY ID# SERVICE REQUEST# <br /> 36 <br /> OWNER/OP RAT0P�� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � N(Lt a n /j <br /> \ Street Number rection" ��LI itreet Nam C Zip Code <br /> HOME Or MAILING MDRESS (If Different from Site Ad e <br /> JA (1 ) I � , OfL Street Number Street Name <br /> CITY, 1 //�� ST{\[�T€ ZIP/ <br /> l��, t.l AL C.� <br /> PHO ``(_ EXT. APN# LAND USE APPLICATION# <br /> PH N rte/ .EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ��;�k(" � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO,a r, r�1� PHONE EXT.�(��'�) /J� <br /> HOME or MAILING 46DRIESS_ ^ FAx <br /> CITY ; t STATE G\ — _-7Zlp) <br /> MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> BILLING ACKN0-1X--6-n(--F <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 th' application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Stand -ds ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , DATE: n <br /> PROPERTY/BUSINESS OWNER❑ OPEIL4TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑C .'Ir�/� �/^ <br /> If'APPLICANT 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 environmentaUsite 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 /> TYPE OF SERVICE REQUESTED: 6, T PAY MENI <br /> REeEivED <br /> COMMENTS: <br /> JAN 2 0 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: Cf V (� DATE: '? b L/ <br /> ASSIGNED TO: /I�'� EMPLOYEE#: �v` DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: U 9 <br /> Fee Amount: C E) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod / i <br /> REVISED 11/17/2003 ,l�f� <br />