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3 0 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE.REQUEST# <br /> OWNER OPERATOR <br /> �1 , ! / S f ICA <br /> n A /[ I + ! A CHECK If BILLING ADDRESS <br /> FACILITY NAME i /^► '�V Ip lLA V 01 A �jAV.` JTLC P, <br /> SITE ADDRESS f I �� , az i �/� c5 T A4h AJ/ CGr3 9 J 3 3 4 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 Street Number Street Name <br /> CITYn �� �� STATE ZIP <br />} 't <br /> a PHONE VII EXT' APN 9 LAND USE APPLICATION# <br /> �)HONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> P } 3 D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTUR /� r ` f J� <br /> j /--L l.. [ 1 CHECK If BILLING AbDRESS t• '. .y <br /> 4 1 \J <br /> BUSINESS NAME 113- PHp E# EXT. <br /> ZJ <br />{ HOME or MAILING ADDRESS FAX# <br /> 66 A I QW C1 <br />} CITY STATE., ZIP <br /> t 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 and FEDERAL laws. <br /> APP ATURREE iQ v 46i r DATE; G <br /> F PROPERTY I BUSINESS OWNER IL'J OPERATOR/MffANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 /> r above site address, hereby authorize the release of any and all results, geotechnical data and/or environmeTntal/site assessment <br /> informatiori to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as iti$ !#the same time it is <br /> provided to me or my representative. <br /> �1Q <br /> TYPE OF SERVICE REOl1ESTED: }. � IMF- <br /> 4 Olt <br /> �3 <br /> COMMENTS: MKI <br /> JOA0100"COUNTY <br /> r <br /> ACCEPTED BY: \ EMPLOYEE#: l DATE: 5 �� 13 <br /> ASSIGNED TO: i �` EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODs: 33 P I E: <br /> Fee Amount: Amount Paid 7L5— <br /> Payment Date <br /> Payment Type Invoice# Check# Received 8y: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 14/17/2003 <br /> 1 <br />