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rw <br /> SAN JOAQL COUNTY ENVIRONMENTAL HEALDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5200 4 ZS 3 4 <br /> OWNER/OPERATOR /J <br /> o`y NECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Nu er Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ` ExT. APN# LAND USE APPLICATION# <br /> 0 3a7��aa-a <br /> PHONE#2 Exr. BOS DISTRICT ][ILO,CAONCODE <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br />� CHECK If BILLING ADDRESS❑ <br /> i <br /> BUExr. <br /> SINESS NAME � PF1�17F# � 2�y <br /> HOME or MmuNG ADDRES§ FAX# / <br /> .2Lk <br /> / <br /> CITYJ) TATfi ZIP(��'f s l� <br /> I V <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 /> 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 Ordi'nan'ce Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: "C-rA"I -� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILL G PARD;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 CouN iY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �j S �� JUN 3 2005 <br /> _ J SAN JOAQUIN COUNTY <br /> O�yr� ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �j ��44-1- <br /> ASSIGNED TO: _ EMPLOYEE#: �j � DATE: �IE. <br /> 3 4S— <br /> Date Service Completed (if already completed): SERVICE CODE: C"2 P 2&01 <br /> Fes Amount: d O Amount Paid Payment Date L10 Ca <br /> Payment Type ✓ Invoice# Check# ` j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />