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SAN JOAQ* COUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEti <br />V1c-e Sk��Ovj ,Tic^ <br />FA'C1LiTY.ID # <br />PH E Exr. <br />0-1 t 2 <br />SERVICE REQUESVC ^ <br />A 21 <br />OWNER/ OPERATOR <br />(4 „) <br />CITY . ` 1 , n <br />CHECK If BILLING ADDRESS <br />FAciuTr NAME (:i� ^ J i <br />bl <br />SITEAID}D�RESS <br />✓ Street Number <br />Direction <br />v'�Dcvl <br />Street Name <br />CI <br />Z1p Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PH//O��NEM�#1 <br />Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Exr. <br />BO,S DISTRICT <br />LACA710N' CODE <br />CONTRACTOR / SERVICE REQUESTOR 1-11 <br />REQUESTOR ,�`" <br />I'Q V 1 tqj <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEti <br />V1c-e Sk��Ovj ,Tic^ <br />PH E Exr. <br />0-1 t 2 <br />HOME Or MAILING ADDRESS i � VO \ , i �� y� _ /� <br />V ` �V �1/� 6 �V <br />(4 „) <br />CITY . ` 1 , n <br />STATE /SAA zip L /I <br />(_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 <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 FEMRAL laws. l <br />APPLICANT'S SIGNATURE: m` DATEb(S: / l \ )D I <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT LJ <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 />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />