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SAN JOAQUT"COUNTY ENVIRONMENTAL HEAL- 'DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C s . <br /> OWNER/OP RATOR - <br /> ,5;6�r/ /! /L' ` eL� CHECK if BIWN ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#t t Exr• APN# LAND USE APPLICATION# <br /> PHONE#T ExT• BOS DISTRICT LOCA-90V CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> (Ali ) ' —1 <br /> HOME or MAILING ADDRESSFAX# <br /> CITY k Cc t GS STATE ZIP <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: <br /> PROPERTY/BUSINESS O WNE OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ < '�/L�( <br /> IfAPPLiCAN'T is not the 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: t/f�uJ U Ar <br /> COMMENTS:�i/1 60»�-.� /Z1��2>' <br /> RECEIVED <br /> NOV 1 6 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONME TAL <br /> ACCEPTED BY: EMPLOYEE#: / ATE: <br /> ASSIGNED TO: f EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: j� — P/E: <br /> Fee Amount: Amount Paid b I Payment Date b S <br /> Payment Type Invoice# Check#o (12 Received By: <br />