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JAN JOAQUIN COUNTY E+'NVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Gj .'30 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR 0 <br /> UI �y I CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> otYAiccs / n r 2 ,�� e <br /> SITE ADDRESS OZ 1�C/ � J ja tL� �_t�-�-� /� r � ��O✓�{c�� ,� `��/! <br /> Street Number Direction T Street Name t city S YI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY A STATE I ZIP 5 / <br /> 01 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> U <br /> PHONE#2 EXT. BOS DISTRICT LOCATIO CODE <br /> ( ) � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORI '^^ m CHECK if BILLING ADDRESS❑ <br /> I BUSINESS NAMEPHONE# EXT' <br /> M "d - Cd n s4 (Lt C4 s (,&q) -�yv <br /> NOME Or MAILING ADDRESS 1 FAX,0-'1) <br /> CITY QC 6y, 1 I STATE (ffi- ZIP q C,, D�_�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,STATE and FED7; laws. <br /> APPLICANT'S SIGNATURE /f DATE: T <br /> PROPERTY/BUSINESS OWNER❑ OPERATO ANAGER ❑ 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 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: p A-)SC f-LL-] -T7 C)•� T <br /> COMMENTS: <br /> u Qi nt d 1i� <br /> S�vUC' <br /> o? SA EN�IFONPARTMEt4T <br /> I <br /> ACCEPTED BY: C tJ t EMPLOYEE#: Z ATE: 7 <br /> ASSIGNED TO: i EMPLOYEE#: 7 37 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �,/ PIE: <br /> q2,0 Z <br /> Fee Amount: !' Amount Paid q!5, � Payment Date 2 ( v <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Goldon Rod <br /> REVISED 11/17/2003 <br />