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SAN JOAQO COUNTY ENVIRONMENTAL HEAL,6EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bAsDoAz) OJT' I� r�z°o-� J-( D--� .S2.010 �0-73 Z-f <br /> OWNER/OPERATOR 1 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _/ -C nCf � C <br /> SITE ADDRESS 2o `f lW�CL���6D RCDC cf sI <br /> J C.ktb195.10,5- <br /> �-d� <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2,Ci ) `�5-y6 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME } �,, f y PHONE�y# / p E.T. <br /> HO E Or MAILING ADD ES FAX# <br /> CITY 57 C' S 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: DATE: <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: US 7- ` PAYMENT <br /> COMMENTS: RECEIVE <br /> JUN - 4 20,i3 <br /> SAN JOAOUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: / �3 <br /> ASSIGNED TO: t EMPLOYEE#: Gy DATE: v / <br /> Date Service Compl (if already c pleted): SERVICE CODE: G P 1 E: <br /> Fee Amount: O'k �� Amount Paid ���0 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />