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SAN JOAQUIN CO NTY ENVIRONM � IL� IERTMENT I SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST S OWNER/OPERATOR CHECK if BILLING ADDRESS i,. FACILITY NAME SITE ADDRESS Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) �' G�JoT Street Number Street Name ;r CITY �J STATE V Zip ��ZO PHONE#1 Ems• APN# LAND USE APPLICATION# PHONE#2 EXT* BOS DISTRICT LOCATION CODE ' CONTRACTOR/ SERVICE REQUESTOR REQUESTOR --� J— .-� CHECK if BILLING ADDRESS r BUSINESS NAME �� PHONE# Ems' �'� r a�= 36,,r-617-r HOME Or MAILING ADD ESS z �© o 3't CITY S STATE r it- ZIP 0 Z4V �Y BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, fl acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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' COUNTY Ordinance Codes,Standards,ST E and FEDEYAL laws. Q APPLICANT'S SIGNATURE:— JDATE: PROPERTY/BCsINESS OWNER❑ PERATOR/MANAGER OTHER AUTHORIZED AGENT El ` 1 ¢s If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title y AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment T information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is !LL'tprovided to me or my representative. l� YPE OF SERVICE REQUESTED: �^ ��i/�Zs�lf�� fGtG� �bOMMENTS: R E �H APR 2 g 2004 Ike) ` O SAN JOA COUNTY I \ ENVIRONMENTAL Q�i DEPARTMENT OYEE r APPROVED BY: 1 #: U�2) DATE: L` EMPLOYEE#: ASSIGNED TO: v DATE: v e Date Service Completed'(if already completed): SERVICE CODE: D j.,( PIE: Fee Amount: Amount Paid -� Payment Date Payment Type Invoice# Check# l�O(p� Received By: ,y EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 s ""'''.roxzx=�'A � _.._. _�^'� .. .... ,-"•fie.