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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property A FACILITY ID# SERVICE REQUEST# <br /> OV <br /> `M �T -rn ->t'a ram fKLf I.�i C r +� —I/ �� (�J <br /> OWNER/OPERATOR` <br /> J^0--EL E. Ck?-Rhi.. h;EFPhi- tAAl',,f- G.-ice CHECK If BILLING ADDRESS <br /> t <br /> FACILITY NAME <br /> SITE ADDRESS Zr�rer�r <br /> E F, <br /> Street Number Direction Street Name city Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) _ , ,�� �Pv r✓ <br /> Street Number Street Name <br /> CITY ==V s STATE r ,e- ZIP y` C <br /> PHONE#1 EXT. APN# may r LAND USE APPLICATION# <br /> PHONE#2 �!`/ EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` _ fT CHECK if BILLING ADDRESS <br /> BUSINESS NAME C::T_:� SP /,', ��C. ! PHONE# _Cy Ems' <br /> (^ 7 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY << STATE r ZIP SG G/Lns <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: i <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ ! <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ! _ /' Ti rl e <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: <br /> COMMENTS: / PAYMENT <br /> ;r 20'� RECEIVED <br /> DEC 2 9 2003 <br /> tf' SANN COUNTY <br /> ENVIRONMENTAL <br /> DEPARTMONT <br /> APPROVED BY: EMPLOYEE#: 1 D DATE: It- . � D� <br /> v <br /> ASSIGNED TO: EMPLOYEE#: rj- DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 Z P I E: C' <br /> Fee Amount: \ Amount Paid 14 I ���'i Payment Date I-L Z4 b3 <br /> Payment Type Invoice# Check# --)Ll_j Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />