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SAN JOAQL COUNTY ENVIRONMENTAL HEALTir: DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR LC CHECK If BILLING ADDRESS❑ <br /> -- 7-� �Gclu, -Td (��S <br /> FACILITY NAME >; I k-- a m `� <br /> SITE ADDRESS I 5 W(DDD V�J <br /> DPM (A\�\O W1A N <br /> nU <br /> V 1 Street Number Direction Street Name cit Zip Code <br /> E or MAILING G ADDRESS (if Different from Site Address) <br /> ac-) ` <br /> a 1 ML'4 P 0 1 re— Street Number Street Name <br /> CITYN A G� CA <br /> ^STATE ZIP 3-3 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (olIti) '-f ` DtiC\ `3 <br /> rPHONE#2 1 EXT BOS DISTRICT LOCATION CODE <br /> l 2"x4) 6 "l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME`�-'I 1 � l�, n ,N(�� � 1 � 1 P�(/ ��� � �ill� EXT. <br /> HOME Or MAILING ADDRESS 1 \�1,� D VL ('Z-6,I) <br /> / `1 62 <br /> CITY '- 1 `'O \ STATE (p Zip <br /> MANS" �� G� c�'S3-7 L <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 <br /> or 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,,�TATE and FE E laws. l <br /> APPLICANT'S SIGNATURE1< ti ✓�� DATE: Ul V J <br /> PROPERTY/BUSINESS OWNER[:] O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BI G 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 an same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: J SAty 46 <br /> JO 20f4 <br /> C_l �TZ1/YLP��jl� f pA4UtN <br /> � Fq� N AOMF COU <br /> �DFp!4&�NT I' <br /> �NT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: �Z�� EMPLOYEE#: �& 41 <br /> DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: C4, P I E: <br /> Fee Amount: S Amount Paid: Payment Date <br /> Payment Type Invoice# T Check# I r-1 Received By: <br /> EHD 48-02-025 / �J J SR FORM(Golden Rod) <br /> / <br /> REVISED 11/17/2003 C6 / <br />