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SAN JOAQUIP -)LINTY ENVIRONMENT AL HEALTF'DEPARTMENT <br /> �-' SERVICE'REQ'UEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK It BILLING-ADDRESStu <br /> FACILITY NAME -y 1 <br /> SITE ADDRESS A//��� ����J//� <br /> Street Number on /" va Stteet Name a 1✓ ri 1 �� Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /x���,/ <br /> Street Number /" Narrb <br /> CITY PTATE ZIP <br /> PHONE#1 Ezr' APN# c " LAN SE APPLICATION# <br /> I &TO, ��¢-��l p Y /4 62-6220 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EzT, <br /> HOME Or MAILING ADDRESS FAX# <br /> TRO 4�cl <br /> I ) <br /> CITY STATE C/' ZIP C�`7iaA <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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPE T /MANAGER ❑ OTHER AUTHORIZED AGENT 'ir�ry/L4a <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: Spy S SL,.,t4dot PAYME <br /> COMMENTS: <br /> r 'y 16�Otto It) a �(• NOV 2 42003 <br /> UIN COUNTY <br /> 0 H�JOAQ AL <br /> ivior,A TP MEtdf <br /> ACCEPTED BY: EMPLOYEE#: / DATE: <br /> ASSIGNED TO: EMPLOYEE#: 1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: l Amount Paid I _. Payment Date (( a ?) <br /> Payment Type . I Invoice# - - Check# J L�63 Rec 1ved By: <br /> EHD 48-02-025 )�I a l �' r SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />