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Ir SAN JOAQI COUNTY ENVIRONMENTAL HEAL DEPARTMENT SERVICE REQUEST Type/qf Busines oLProlprty FACILITY ID # BUSINESS NAM 9t- Z -&7lbPJ �?6 C, /I. SERVICE REQUEST # oma% 7� G 6'0 2 Z-, F, 2, �,�' (� 35'74, OWNER / OPER T CHECK If BILLING ADDRESS 1 c ll„ it'jQ[J APPROVED EIr 9, um FACILITY NAME J, DATE: �C' /A 3 SITA ADDRESS EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: F Street Number Direction Amount Paid Stet ame t Zit Code HOME or MAILING ADDRESS (If Different from Site Address) �✓ Check # 7 2,97 X jn j Street Number eet Na�" " `-/ CITYJ � q E Y515_ zip PHONE #1 EXT. 1909) �15/- 3195 APN # LAND USE APPLICATION # Pp�#2 EXT• 7, G�9 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE RE, QUESTOR REQUEST0 t&aJ CHECK if BILLING ADDRESS BUSINESS NAM 9t- Z -&7lbPJ �?6 C, /I. PHONE# EXT. HOME Or MAILING ADDRESS�35-, /, �e FAX# 2— CITY � � �n TATE ZIP BILLING ACKNO EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this plication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Slander s, TATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINFSSOWNER❑ OPFRATOR/MANACER ❑ OT]n-mAUTHORIZED AGENT t If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTti DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Gia S'T �r�0/ 7— RFOEIVED COMMENTS: OCT 212003 SAN COUNTY PUBLICO HEQALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPROVED EIr 9, um EMPLOYEE #: U / DATE: �C' /A 3 ASSIGNED TO: % Lam,° EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: F P I E: 3 p Fee Amount: j e �' Amount Paid Payment Date Payment Type Invoice # Check # 7 2,97 Received By: EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM