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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VI E REQUEST# <br /> OWNER/OPERATRR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME _l <br /> SITE ADDRESS ,��l , -. � C&D <br /> Street Number Directions ~tree[Name Lit Zi Code <br /> HOME cor/MM]AILING ADDRESS (if Different <br /> from Site Address) ,)]� <br /> r oC L 1 `1 f`� c-, ,4 �(L v Street Number Street Name <br /> CITY STATE Zip <br /> Los ti r14- (?e l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. -11 BOS DISTRICT LOCATION CODE <br /> (air ) 11� 3- N(�35 <br /> REQUESTOR <br /> CONTRACTOR / SERVICE REQUESTOR <br /> C� <br /> bd`v CHECK if BILLING ADDRESS Lot <br /> BUSINESS NAME 'T PHONE# EXT. <br /> SniLkS5Ctf� 2At��a� ��eet+_ lie. llt;bl, > ` <br /> HOME or MA LING ADDRESS FAX# <br /> `"19`f5 >fL204.'rLA'V- -36 3 ( ) <br /> CITY < � STATEri ZIP %2(31 <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 FEDERAL/la/ws. Z APPLICANT'S SIGNATURE: C� -)�l�t,Ct�rl �HL`f ' DATE: !v� �cJ�ZG!�f <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environme I/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andcr�'Nr <br /> ime it is <br /> provided to me or my representative. N <br /> TYPE OF SERVICE REQUESTED: t' /1;- d P® <br /> COMMENTS: <br /> sAHJ <br /> N AQUIH <br /> U <br /> �CTyp°Fpm �NTy <br /> T <br /> ACCEPTED BY: EMPLOYEE#: =0 DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already col mpleted): SERVICE CODE: P 1 E: 1 <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />