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SAN JOAQUIN�UNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /!1� 11 <br /> l.,C�-yl 4 IL.0 T� C-@ <br /> ,1 �C� �'�I� � HECK if BILLING ADDRESS <br /> I t SA O F-C- , �ijl (�� <br /> FACILITY NAME I <br /> l,i �.A - o le Lx UvA <br /> SITE ADDRESS 0 IF <br /> Street Number Direction '`l Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> &A P, Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CC"+1�CI C'� ' CHECK if BILLING ADDRESS <br /> Will IAM <br /> BUSINESS NAME n PHONE# EXT. <br /> tA <br /> HOME Or AILING ADDRESS FAX# <br /> CITY ` STATE ZIP Q 5(6 2 m <br /> 1�C)I,,V t J � `J <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,S ands, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNAT DATE: C_ <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required k 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 /> � PAYMENT <br /> TYPE OF SERVICE REQUESTED: EB <br /> - <br /> COMMENTS: <br /> FEB 19 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> -1 Payment ate a �b.p � , <br /> Fee Amo�lnt: Amount Paid r,, ,� <br /> Payment Type — Invoice# Check# Received By: ✓ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />