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so I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LA ood 3 co3!�- Scc c S �-( -2 <br /> OWNER/OPERATOR <br /> *5�/��' �4�/ _��//f J� ✓ //f CHECK If BILLING ADDRESS <br /> FACILITY NAME Ln 'nom ���yC�/ �y /�S LSC:/ �-�C� <br /> SITE ADDRESS 5— �,. �SC� <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> AI <br /> 0'67a x v ' Street Number Street Name <br /> CITY �1/� STATE ^ ZIP 7e; <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> MID <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J- / �> PHONE# ��~ P U EXT.-- — <br /> HOME or MAILING ADDRESS FAX# <br /> CITYL��� 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 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �T DATE: 5 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT /rTT*�/}7��— <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ri F w :D <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the pr pd rt�'located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme�nlltnaly/sitap a&sL Intit <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and RAR safne time It is <br /> provided to me or my representative. COUNT`( <br /> TYPE OF SERVICE REQUESTED: US.T FWAVIONPARTME T <br /> COMMENTS: r� �YI <br /> �'/F�l1[�!�" l�/�'�'l/✓E �s'Li��I-��� li%'i fes' l�J�t'�'�,�'C/�' �� 9�- <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: YJ O <br /> Date Service Completed (if alr a y completed): SERVICE CODE: Q P I E: �3 <br /> Fee Amount: Amount Paid -1 Payment Date -5 1 0 V6 <br /> Payment Type �/ Invoice# Check# a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod)�v <br /> REVISED 11/17/2003 <br />