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--)AINJVA(2U11N k,0U1NlY hINV1RUIN1VILINlALnEAL1'HVEYAH'11VILIN.1 <br /> SERVICE REQUEST <br /> Type of Business or Property' FACILITY ID# SERVICE REQUEST# <br /> 73D 5Q 5 <br /> OWNER/OPERATOR <br /> TCHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> eea("-)r SITE ADDRESS I� I o r' 5a 1 <br /> Street Number Direction �T Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6-'? Street Number Street Name <br /> CITYPao STATE ZIP -3 A <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (ac) L4-7-7 311 ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �- <br /> A" �p \\ <br /> t N-S E—Z t K�i CHECK if BILLING ADDRESS <br /> BUSINESS NAME ��6t ���` PHONE# EXT. <br /> A, (gI a ) e,�Z- X44 <br /> HOME or MAILING ADDRESS FAX# <br /> 00-1 Lo . �t✓�r..«�/� olr� . Sc� t�� (SIS) 84Z - 37(�,d <br /> CITY F::u� �� STATE (� � ZIP 9 1 <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 /> 1 also certify that I have prepared this application nd that the work to be performed will be done in accordance with all SAN JOAOUIN <br /> COUNTY Ordinance Codes,Standards, STATE a �DERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: 3�4✓ o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M NAG R ❑ OTHER AUTHORIZED AGENT PtoJ FGT1�G�f L <br /> If APPLICANT is not the BILLING PARTY,proof of awhorization to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: I 1 retI Q <br /> PAYmFNT- <br /> COMMENTS: REC*Fz I VE p <br /> MAR 4 2003 <br /> CAN JOAQUIN COUNTY <br /> P0BLIC HEALTH EW ONMENTAL HEATH DPASION <br /> APPROVED BY: r� � EMPLOYEE#: 'ZZ U DATE: - -3 <br /> ASSIGNED TO: Y�^` EMPLOYEE#: ? �7D DATE: <br /> Date Service Completed (if already completed): SEaV10E CODE: C P 1 E:_�_? <br /> Fee Amount: 'ZAmount Paid '� .� Payment Date 3 O� <br /> Payment Type Invoice# Check# ',7p Received By: <br /> _ EHD 48-01-025 SERVICE REQUEST FOR1G1� <br /> REVISED 6-5-02 <br />