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SAN JOAQUINvUNTY ENVIRONMENTAL HEALTH DI RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Proper" FACILITY ID# SERVICE REQUEST# <br /> Y/ (,fsi /^25S 52aDyl0 �Z <br /> OWNER/OPERATOR // <br /> /tmNAME <br /> I ' 1 ` err /v CHECK IT BILLING ADDRESS <br /> FAcINAMEt' J <br /> SITEADDRESS <br /> / W1�/' OIX 1 j `/ S A „ /J"'� <br /> 15-0 V l 9[rNt u Direction v I V `lc"- , Zi cue. <br /> HOME Or MAILING ADDRESS ( DH%Mnt from Site Address) <br /> Won <br /> Street Number Street Name <br /> CI W 3b J C STA ZIP \ 1 T <br /> PPg1E#7 Exr. APN# LAND USE APPLICATION# �l dtJ <br /> EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' CHECKif BILLING ADDRESS <br /> BUSINESS NAME PHONE <br /> HOME or MAILING ADDRESS �!` FAX# <br /> 1 1 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> -and <br /> 'FEDERAL laws. q -7 <br /> APPLICANT'S SIGNATURE-/%IVI�f///VV DATE: /t/O��O.� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ Or MERAUTHORIZPAAGENTO <br /> If APPLICANT is not the BILLING PARTY proof oJaulhorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: F'N� <br /> r=tF_C- <br /> F EB - 2 Zoos <br /> SAN JOAQUIN COUNTY <br /> "WitiONMENTP <br /> ACCEPTED BY: EMPLOYEE#: QL.+. ArcET I1 DE ATE: <br /> ASSIGNED TO: EMPLOYEE#: ^'_' rI DATE: <br /> Date Service Completed IH already Completed): SERVICE CODE: PIE: Z <br /> Fee Amount: Amount Paid / Payment Date �- <br /> Payment Ty Q(3 Invoice# Check# 3051 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />