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Q <br /> UUNTY ENVIRONMENTAL HEAL? DEPARTME <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b 3 .5 � yss3 a <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> '—•. <br /> FACILITY NAME <br /> SITE ADDRESS \�� �p <br /> 3 E Street Number Direction Street Name J Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Ad dress) <br /> W / ' Street Number Street Name <br /> CITY T E ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (a01) X30 _7001 <br /> PHONE#T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR w� <br /> +Z�13� P CHECK if BILLING ADDRESS <br /> BUSINESS NAME LCIS `7(4p PHONE# ExT/ ' <br /> DI ) 8 Y -SS7 (o <br /> HOME Or MAILING ADDRESS FAX# <br /> -�9 9 7 �--e-C Wo Id r ( ) <br /> CIN �}—p7 G C, J*N STATE ZI� ��30 <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 busine s identified on this form <br /> I also certify that I have prepared this p cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards S ATE and F laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 0--- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAM 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: <br /> COMMENTS: <br /> 1 TO <br /> J� <br /> Now' PQME�P�N� <br /> SP�Nv\P O PP��M <br /> ACCEPTED BY: EMPLOYEE#: DATE: N( <br /> ASSIGNED TO: / V Lf-3 EMPLOYEE#: DATE: (L <br /> Date Service Completed (if already completed): SERVICE CODE: b 6 P 1 E:a� <br /> Fee Amount: 3 Amount Paid -1 3, Q p Payment Date O b <br /> Payment Type L/ Invoice# Check# Received By: <br /> EHD 48-02-025 ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />