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SAN JOA r-'-N COUNTY ENVIRONMENTAL HE DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER)OPERATO l <br /> 1 UOUWJ <br /> �/ _/ /l.. CHECK If BILLING ADDRESS <br /> l �•C. U[/l/ LAS <br /> iTr <br /> LITY NAME <br /> DDRESS <br /> z /� �e <br /> Street Number Are, <br /> tion -r` <br /> _ <br /> /SWAeI Name � s 2i Code <br /> HOME Or MA G A RES$., tRifferent Ohm Sit '"Address) )ry <br /> `J L V '' t 1 Number Street Name <br /> CITY I STArE zip <br /> PHONE#t EXT. AP�# n LAND USE APPLICATION <br /> � L� # <br /> I , g/ .7 � ��' PA -yG Su <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SER ICE RE' QUESTOR <br /> REQUEST V( , <br /> O CHECK If BILLING ADDRESS <br /> BUSINESS PHONE# <br /> EZT. <br /> ;4 7^ I7Ob <br /> HOME Or ApNG AjDRE <br /> vCl{ ( ZP77o �—f01r <br /> CITY ! &Li— STATE Co— ZIP V S-L 3 Z <br /> BILLING ACICNOWI.EDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DsrARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared thi pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StanI ds,ST 7rand FEDERAL.laws. <br /> APPLICANT'SSIGNATUR DATE: %SLD3 <br /> PItOeF➢ITV/BUSINFSS OWNF.11❑ OPERATOR/MANAGER ❑ OTH llt AUTHORIZED AGENT❑ <br /> /f/111PLICANT is 1101 the/JILL/NC.'/',IM proof of alithoriLation to.sign is required Tide <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 file SAN JOAQUIN COUNTY ENVIRONMENTAL HEAIAII DEPARTMIiNT as soon as it is available anNI„!he same time it is <br /> provided to me or my representative. AYME 1 <br /> TYPE OF SERVICE REQUESTED: v1 <br /> COMMENTS: /I/L/6GrNII3lQ�. JUL2 <br /> N COUNTY <br /> ,1).j7' G ENV RONMENSAN EALTHE LRHIDNSSION <br /> APPROVED BY: � EMPLOYEE#: rJ. �- DATE: <br /> ASSIGNED TO: ` !^ �- EMPLOYEE#: J-? (K( DATE: <br /> I • '�.' <br /> Date Service Completed (if already completed): SERVICE CODE: _ ,�, PIE: - (/ <br /> Fee Amount: Amount Paid Payment Date - -� <br /> \4\ Payment Type Invoice# Check# �, i Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> RFVISFD 6-5-02 <br />