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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALDEPARTMENT O 0 SERVICE REQUEST 4 Type of Business or Property CHECK if BILLING ADDRESS❑ BUSINESS NAME ��Cr'(�,1 �f1�/+I�lJhimz�7�+tI ty�ahq �ni,r> S�rVIC�, PHONE # ILS FACILITY ID # HOME or MAILING ADDRESS R Go)( Ply 2 SERVICE REQUEST # OWNER/ OPERATOR CGI, 0rhtc, iik w 4 CITY V M f `6CA STATE ZIP CHECK if BILLING ADDRESS FACILITY NAME Cc0+1h4. Dept. cry PU9UC NEPVTHEAI N OIVISIOti �NVIRONEN+E SITE ADDRESS Street Number Direction t Street Name Cit Zip Code HOME or MAILING ADDRESS (if Different from Site Address) '1555' F{ r3 1(i + Street Number DATE: Street Name CITY SERVICE CODED: O P ! E: 3 3 SATE ZIP PHONE #1 ( ) EXT. Payment Date APN # OSI- 100-03 LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR Cell -1t - '2s�i -`rt? 1 CHECK if BILLING ADDRESS❑ BUSINESS NAME ��Cr'(�,1 �f1�/+I�lJhimz�7�+tI ty�ahq �ni,r> S�rVIC�, PHONE # ILS / ` EXT. ¢21 +61L HOME or MAILING ADDRESS R Go)( Ply 2 FAX # (96-) RECEIVED CITY V M f `6CA STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FK.DERAL laws. / 1�r 21 APPLICANT'S SIGNATURE: DATE:�— PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is Drovided to me or my representative. TYPE OF SERVICE REQUESTED: Li ST 1 Vi S 1 (A COMMENTS: t� PAYMENT FiE J j RECEIVED &Z NOV 2 5 200? JOAQ�IN COV CE SAN JOAQUIN COUNTY PU9UC NEPVTHEAI N OIVISIOti �NVIRONEN+E PUBLIC HEALTH SERVICES APPROVED BY: EMPLOYEE #: Z`Lu L JQJ DATE: ASSIGNED TO: EMPLOYEE #:ff DATE: Date Service Completed (if already completed): SERVICE CODED: O P ! E: 3 3 Fee Amount: , Amount Paid 1Z-- Payment Date Payment Type �✓ Invoice # Check # 3� s. Received By: EHD 48.01-025 �__ VICE REQUEST FORM REVISED 6-5-62 ry