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SAN JOAQVTaJ COUNTY ENVIRONMENTAL HEAL-1 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5.1200 2—&00 <br /> OWNER/OPERATOR <br /> `O CHECK If BILLING ADDRESS <br /> FACILITY NAME // <br /> SITE ADDRESS Zlv� 70oY Ct'(t/� <br /> Street Number mreeNon [reef a C ZI Code <br /> HOME <br /> or <br /> MAILING ADDRESS (I Differentfrom Site Address) <br /> `&/ 0 r � - trcet Number Street Name <br /> CITY STATE iA ZIP <br /> PHONE#1 T• # DE APPLICATION# <br /> 1 / 5 L �I , , 5 <br /> PHONER OS DISTRICT LOCA CODE <br /> CONTRACT VICE REQUESTOR <br /> REQUESTOR / j/ <br /> [:NECK If BILLING ADDRESS <br /> BUSINESS NAMPHONE# �' <br /> Z4 <br /> 1 334- 6523 <br /> HOME Or MAILING AD DR SS jj FAx# <br /> CITY n / STATE // ZIP G SZ 4-O <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 projector <br /> activity will be billed to me or my business as identified on this form a <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE(.—� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ICJ <br /> IjAPPLICANTisnotthe BILLINGPARTY 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: U, <br /> COMMENTS: 7a=-� �,�, �put RECEIVED <br /> txca�r u/ I`"7/ 3 � JUN 6 2m <br /> Ir v SAN JOAQUIN COUNTY <br /> _ENVIRONMENTAL <br /> f�7• <br /> ACCEPTED BY: D L I l/� t EMPLOYEE#: DATE: (CES <br /> 3Z <br /> ASSIGNED TO: rl r yj , N A EMPLOYEE#: J 3 DATE: b <br /> Date Service Completed (if already completed): SERVICE CODE: i S P/E: oZG��3 <br /> Fee Amount: ( �jr._ G� 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 />