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Y SAN JOAQUIN ' -)UNTY ENVIRONMENTAL HEALTH 7PARTMENT <br /> ,*me J <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( htt'l2e-N �2 �2�3 <br /> OWNER/OPERATOR <br /> /N, /C 6 � i/�1�T/�e-6- 6x -640 ���� S cnJ l /A` �AE CHECK if BILLING ADDRESS El <br /> FACILITY NAME 4J <br /> SITE ADDRESS <br /> 7` Street Number I Direction Street Name city e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR XU 1¢/L <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1E j Z 2�CIA�Cn/ P NE p EXT. <br /> HOME or MAILLNADDRESS FAx# <br /> CITYAG— $TeE_t zip CJS ® <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 andFEDERALlaws. <br /> APPLICANT'S SIGNATURE: C !�• . DATE: ///z,/0 q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT L O�✓"" � <br /> IfAPPLICANT is not the BILLING PAR7T_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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: T7-f- S S *�)` Ati ��(�_C RECEiVED <br /> COMMENTS: L-( Q - .,-)A S—) <br /> i/zt 9't � vim, - rte,;, �.C4� 7t4- of � JAN 2 004 <br /> Z�YID y /� a�i �i�2j�Nititi SAN JOAQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �Lt L) EMPLOYEE#: Q 3 Z( DATE: / (L <br /> ASSIGNED TO: /(t S S EMPLOYEE#: (4s DATE: / L <br /> Date Service Completed (if already completed): SERVICE CODE: �✓ 2 PIE: 42 <br /> Fee Amount: CCS Amount Paid *7/ a�- Payment Date <br /> Payment Type v' Invoice# Check# Receiived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />