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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> r <br /> SITE DDRESS F ] fj �� 160 <br /> street Numher. [�'recfion [..�•„" t reel Name CI Zip 11ade <br /> Hai E Of MAILINGDRES� (I fDitferen rem ite Address) <br /> DC- Street Number Street Namei <br /> CITY S 6 C I� V .STATE Zip <br /> PHONE fl Exr• APN# LAND USE APPLICATION# <br /> 6 3 9 <br /> PHONE#2 EXT. BOS DISTRICT k LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � � �y} <br /> �!f CHEEK 4f SI['•_!N';ADDRESS <br /> BUSINESS NAME PHONE# � EXT. <br /> POW Ana Lplce5f6- 3S� <br /> HOME or MAILING ADD SS ( FAX# <br /> CITY LOA STATE C zip z O <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 /> APPLICANT'S SIGNATURE: D44 &WA DATE: <br /> PROPERTY/BUSINESS OWNER 0 OP ORI MANAGER © OTHER AUTHORIZED AGENT D <br /> IfAPPLICANT is not the BILLING PAR proof of authorization to sign/s required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time it Is provided to me or <br /> my representative. ) <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> P <br /> AECE1VED <br /> MAI I W6 <br /> SAN J AQUMIENO� 1 <br /> ACCEPTED BY: - EMPLOYEE#: t r- Pei <br /> _ j 1 <br /> ASSIGNED TO: ���. S sSl it/� EMPLOYEE#: DATE: i ! <br /> Date Setv€ce Competed (If already completed): SERVICE CODE 5�(P " SPIEo{ <br /> Fee Amount: .9 Amount Paid_ �'�(� -- Payment Date "2• �(0 <br /> Payment Type l.ih Invoice# L Check# Raceived By <br /> 412 <br /> END 48-02-025 SR FORM(Golden Rod) <br /> 07!17108 <br /> 5 <br />