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SAN JOAQUI 9 <br /> OUNTY ENVIRONMENTAL HEALT EPARTMENT °= <br /> SERVICE REQUEST <br /> Type of Business or Property ACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CJAS�� JL <br /> FACILITY NAME <br /> TE ADDRESS /qjjj' /+ TL <br /> "Q. Number Direction Po'-Cl <br /> lT C( 1 Street Name Cit Zi 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 /> (q3-4 - �A q1 --c1 c,` q <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> urj CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Exr. <br /> OlL ra ( ) o� �9 ^�1 d <br /> HOME Or MAILING ADDRESS FAX <br /> o A ty ( —3 L — o Sa <br /> CITY Jul STATECA ZIP Q p <br /> BILLING AC OWLEDGEMENT: 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 /> 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, YA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 46E/4 T DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENTOr,r�1r <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require �J Title V <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 a�4e same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VELD <br /> COMMENTS: ri <br /> S �+ °` 2007 <br /> XPIRED N N RpUiNCOU <br /> STH p pq�NTq�N <br /> TIyEM, <br /> ACCEPTED BY: EMPLOYEE#: `! DATE: ..2 <br /> ASSIGNED TO: EMPLOYEE#: 6 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 8 PIE: <br /> Fee Amount: a Amount Paid Payment Date <br /> Payment Type ✓' Invoice# Check# '3 Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />