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, <br /> 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property/ FACILITY ID# SERVICE REQUEST# <br /> No 0 <br /> kc\ <br /> C1* <br /> QWNER/OPERATOR <br /> CHECK if BILLING.ADDRESS E] <br /> l AGILITY NAME - - - --- — - <br /> - <br /> _. `� (�c� <br /> SI7EADDRESS f„ V I( Too STS t �1 1 �J� <br /> StreetNumber Direction Street Name Co Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> s Street Number Street Name <br /> 'CITY STATE ZIP <br /> a. <br /> s . <br /> A <br /> PHONE#1 Exr• FAPN LAND USE APPLICATION#. <br /> 4 x fz <br /> pWONE#T ,;. T• BOS DISTRICT LOCATION CODE <br /> ilnliv <br /> u <br /> - CONTRACTOR/ SERVICE REQUESTOR <br /> RE(�UESTOR <br /> ! CHECK if BILLING ADDRESS <br /> i81751NESS NAME \ ^ ` (NONE <br /> � 1 ` cZISA <br /> I•lOME t)r WAILING ADDRESS. FAX# <br /> 25 35 ( ►, GtCQ 1-C� 32 <br /> -- <br /> k' Crrsr;. STATE ZIP <br /> BLIl!1O At.KNQLFGEIVIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge thaf;all site and/or project specific ENviRo1�1TAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity-willbe-billed to me:or my.business:as.identified on-this form <br /> �,aLso'certify that.I.jiave,.prepared;this application and that the work to be performed will be done in accordance with all SAN JoAQu1N <br /> GOiITY Ordinance Codes,Standgrds,.STATE and:FpE)ZAI laws. <br /> AI'PI,ICANT-S SIGNA.TUI2E lSl_)�.l J DATE: <br /> 4 . <br /> PROPERTY/'BUSINESS OWNER OPERATOR/:MANAGER O OTHER'AUTHORIZED AGENT <br /> fAPPLIGi1&is not.the BILLmPAR TY proof of authorization to sign is required Title <br /> AUTHORISATIONTO RELEASE M-WORIFIA:TION W_ hen applicable,I, the.-owner or operator of the property located at the <br /> e love Ite adtf�ress, ;heteb authorize t e release of any and:.all results; geotechnical data:and/or .environmental/site-assessment <br /> ilY urination tt the SAN Jo QU1N GOI1bTI Y ENVIItoNMENTAT'HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provrde�to me or my xepreSentative . ---- <br /> "s COMMENTS <br /> _ -- - PAYMENT <br /> RECEIVED . <br /> SEP -20 - <br /> g <br /> r' } — t3AN JOAQUIN COUNTY. <br /> ,.m.. ENYIRONM <br /> t AI;CEPTEDBY v !' EdAP19YEE#: DATE: <br /> v <br /> SIGNED TA 'EISAPGOYEE#C -DATE. 12 <br /> DTZ <br /> Date service iCompleted (if already Coo'mpleted): SERVICE CODE: I E: <br /> P <br /> x l=ee Amount J Y At�ourif 1*aid `t - f'aymenf Date '� C1 Z <br /> Q vD <br /> - - 6 <br /> 7 fsyment Type Invoice# Check# Received By. <br />