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SAN JOAQUPT C(UJNTY ENVIItONMENTAL HEALT 7EPARTMENT <br /> .I. <br /> " �• SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GO-- JIAIE2C/AZ- '5���1S <br /> OWNER/OPERATOR <br /> &/L DT n/ t CHECK if BILLING ADORESSri <br /> FACILITY NAME <br /> PR PO EDMAD2u Ro�D V-f1NESS PARK <br /> SITE ADDRESS Irl— MAP Zz fi it 4 A r-14 9S 33 o <br /> / Street Number Direction Street Nam^ Ci Zip Code <br /> HOME Or MAILING ADDRESS �s(.If.�DAiifferent from Site Address) <br /> 1�5-0 / <br /> Q 1A 2u Street Number Street Name <br /> CITY STATE ^A ZIP ps 3-5� <br /> LA-T��oP I <br /> PHONE#1EXT' AP # LAND USE APPLI ATION# <br /> Z4! -¢/o -37, 4z, 41 /V A <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ r � s ` I� Or <br /> -/ CHECK if BILLING ADDRESS <br /> BUSINESS NAME t^_�NS PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# / <br /> nO , .30 7T4 ( ) C�ri08 'Z�yfJ <br /> CITY uRLO G STATE CA ZIP S -?g/ <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 Ordinance Codes,Standards, E and F laws. <br /> APPLICANT'S SIGNATURE: DATE: 11-7-1-03 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY 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 envirommental/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: N/Tl?ATE LSAA/NL�i f0/L s!(/r/�DtL/fY Qf7[(D R NT <br /> COMMENTS: AOV /G 2003 <br /> JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Of <br /> ACCEPTED BY: EMPLOYEE#: DATE: / O <br /> ASSIGNEDTO: EMPLOYEE#: c/ 7 DATE: <br /> Date Service Complete if already completed): SERVICE CODE: 5 PI E: d <br /> Fee Amount: - 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 />