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SAN JOAQLOOUNTY ENVIRONMENTAL HEALT. EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ^� J '^ { j CHECK If BILLING ADDRESS <br /> Irl � J <br /> FACILITY NAME <br /> SITE ADDRESS "ZCl (k LUQ lti �►�(,a-(�f �,L�-�c •� $�Z a�I <br /> Street Number Direction Street Name k' City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / L' 'e <br /> S. <br /> —7�7 -1- l� v <br /> / L t I l 2� Street Number Street Name <br /> CITYSTATE;y� ZIP 3 <br /> Itk) A r <br /> PHONE#1 - ExT. APN# LAND USE APPLICATION# <br /> rl(,� ) � � � - I � � > 0e 4- IL <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CppE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME �� � ` PHONE# ��'^ �+ EXT. <br /> ►��J �� ✓ 711�1 <br /> HOME or MAILING ADDRESS - FAX# <br /> CITY C`L 2- <br /> 1 <br /> STATE C ZIP O Z (2 <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 JOAQUfN <br /> COUNTY Ordinance Codes,Stand4OPE <br /> nd FE4D L laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 Ll I _ <br /> PROPERTY/BUSINESS OWNER /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PART);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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT as soon as it is available a d at the same time it is <br /> provided to me or my representative. 'AY <br /> TYPE OF SERVICE REQUESTED: 5� � `PI�/l CC)) /kl eD <br /> COMMENTS: a 04 (U,4 <br /> SAN JOAQUIN COUNTY <br /> HEALTH ROMENTAL <br /> DEPARTMENT <br /> ACCEPTED BY: f ` EMPLOYEE#: DATE: Z j� ILL, - <br /> ASSIGNED TO: Zv\ EMPLOYEE#: DATE: <br /> Date Service Co pleted (if already completed): SERVICE CODE: P/E: L p 1 <br /> Fee Amount: Z7 �7 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 />