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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ppSERVICE REQUEST# <br /> c-0 <br /> O,W(JER I OPE OR <br /> ,,T�LEll1.LX1 ` 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME Co.-Fe, <br /> SITEADDRESS <br /> a55a5 Street Number Dlredion Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) e` ,1`)lLone T.2,� V,-`�„ r-�, <br /> 6 '-Sttreet Number Street Name <br /> CITY �5L ,, on STATE ZIP"S�n D <br /> PH0NE#1 �I ExT. APN# LAND USE APPLICATION# 1.•� L <br /> (&gI UZC) aj(&�-, p� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR a <br /> 0O CHECK If BILLING ADDRESS <br /> BUSINESS NAME 0/ 0 I �� /�� PHONE Exr. <br /> HOME [LING ADDRESS <br /> -�-�J FAx# <br /> CITY t A of STATE CP ZIP O�S LJ�O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, o`peeraator 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St s, <br /> APPLICANT'S SIGNAT DATE: 2D2A <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER A UTHORI7,ED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 t0 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. r <br /> r P9 <br /> TYPE OF SERVICE REQUESTED: V ��� (xc C <br /> 16 -4;ALF <br /> COMMENTS: JFp <br /> %ry1OgQUiN ?O?0 <br /> H RO CO <br /> UN FNTg4 71 <br /> '9RT,yFNT <br /> ACCEPTED BY: M Jl EMPLOYEE#: DATE: <br /> ASSIGNEDTO: v�VLI \ \ l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: (0 I PIE: <br /> Fee Amount: \S-Z, Amount Paid /Saz 6 Payment Date cl / <br /> Payment Type Invoice# Check# ' /3 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S <br />