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G�IgG!G'GG <br /> 0 2oVAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENV1R0NM,EN` HEALTH SERVICE REQUEST <br /> Type dMM6Ve6iProperty FACILITY ID# SERVICE REQUEST# <br /> � iL ]Fs <br /> � s i 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �� �/�� � Q�13� �"'fs`•� <br /> SITE ADDRESS 29�lS �ec/ <br /> Street Number Dirtion Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> a6f41v 49 e93 Street Number Street Name <br /> CITY STATE ZIP�A��� <br /> PHONE#1 EXT• APN# 3 LAND USE APPLICATION# <br /> 44� SZy -ti/�/ �s= <br /> PHONE#Z EXT• BOS DISTRICTLOCATION CODE <br /> ( ) i7l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �. PHONE# EXT. p <br /> c�"t7 <br /> HOME or MAILING ADDRESS FAx# <br /> ZW <br /> CITY STATE ef,41, <br /> ZIP Q6 <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: ���jp —� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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. nn __ p <br /> TYPE OF SERVICE REQUESTED: l�T T ! r� cam(T <br /> COMMENTS: <br /> 01 EIV T <br /> l/15/xAg �i�GAl l/ o� ¢. .��% /!r d /SFR 11EAL TH <br /> ACCEPTED BY: 0 L-L —C , O—A EMPLOYEE#: © J� DATE: <br /> ASSIGNED TO: C l -k" EMPLOYEE#: C f-&3(, DATE: -711 1 ),? <br /> Date Service Completed (if already completed): SERVICE CODE: l P I E: 2 3 L,k <br /> Fee Amount: 1(� 1 Amount Paid Payment Date 1 0 <br /> Payment Type ✓ Invoice# Check# 0 25 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />