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JAN JOAQUIN COUNTY 9NVIR3ONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '�ktii R GSD �`T' — L 3,-o Ti- S 1 -7 / �e <br /> OWNER/OPERATOR rH� <br /> t4 t- 1 N f S � CK If BILLING ADDRESS <br /> FACILITY NAME 11.3 <br /> W t WJe r"e ��e <br /> SITEADDRESS [ ��rl�,e,P AE - Z0 <br /> Street Number Direction ( Street Name e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> .--/9,0 rq OQ re- Street Number Street Name <br /> CITYSTATE ZIP <br /> ates,•dc el;v • O 2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( �') 766 - /211 -7 D1'1 - 090 - 02 065- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 13 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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,St4TAT DERAL laws. p� <br /> APPLICANT'S SIGNAT <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER El--- <br /> fd OTHER AUTHORIZED AGENTUC� <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. ,� p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: /)7C�o <br /> PSG � 4 <br /> Nr <br /> PL <br /> � "OVM <br /> N of <br /> pP <br /> ACCEPTED BY: v L[ 1 �. EMPLOYEE#: 3 2 DATE: ?/,)- <br /> , <br /> ASSIGNED TO: �S EMPLOYEE M DATE: � Z 4 f'07 <br /> Date Service Completed (if already completed): SERVICE CODE: S Z'-2— PIE: 42 0/ <br /> Fee Amount: �7 , L,Z-, Amount Paid l . Cp Payment Date <br /> Payment Type Invoice# Check# �,G 7.D- Re eived By: <br /> EHD 48-02-025 SR FORM'(oolden'Rod) <br /> REVISED 11/17/2003 <br />