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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 0 SERVICE REQUEST <br /> T e of Busi ess or Property FACILITY ID# SERVICE REQUEST# <br /> -f NER/ OPE\AOR <br /> + CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ((� _ I/ q5 <br /> TjStreet Number D ection Stree(NN K Zip Code <br /> HOME Or MAILING ADDRESSIf rent from ' e Address1 <br /> l <br /> ADDRESS ( <br /> Di Street Number I/ �Xeet Name <br /> CITY STA C/, I <br /> J L/ <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> �.# EXT. BOS DISTRICT LOCATION CODE <br /> P <br /> -C) 3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# EXT. <br /> i-6 <br /> HOME or MAILING ADDRESS / FAx <br /> CITYI, R TATE ZIP <br /> J V 6t <br /> 4 2 <br /> BILLING ACKNOW EDGEMENT: 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, S A E and FEDERAL laws. /APPLICANT'S SIGNATURE:— aDATE: k ,3166;� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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. <br /> TYPE OF SERVICE REQUESTED: U 1 <br /> COMMENTS: <br /> RECEIVE <br /> OCT 14 2005 <br /> SAN <br /> ENOIRCOUNTY <br /> ONMEN AL <br /> V <br /> ACCEPTED BY: C)L t�;C t Yn q EMPLOYEE#: �Z DATE: <br /> ASSIGNED TO: t I I I J� �` �t EMPLOYEE#: 0-753 DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: s&C Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />