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1-co P�,4 <br /> SAN JOAQUI�, 4:0UNTY ENVIRONMENTAL HEALAEP -1 i i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ivitkVICEReQUEST# <br /> LuEa <br /> OWNER iOPERATOR PE I j If6iu" �► Mms❑ <br /> FACILITY NAME Cc�A vc/-) ^I (S , C <br /> SITE ADDRESSC�'?' )3 0 �� -))C� -+ Cktot� <br /> Street Number Dlrectlon treat Name C �/ L Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> St tt a � /�.i <br /> Street Number O <br /> CITY �_' ' �"� STATE <br /> PHONE#1 Err. APN LAND USE APPLICATION� <br /> O'Cri) c - 6�'CCP <br /> PHONE#2130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Exr. <br /> HOME or MAILING ADDRESS �X - FAX# <br /> CITY STATE C� zip 1 5 <br /> BILLING ACKNOWLEDGEMENT: I, the unders" ned 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 aFf DERAL laws. /�� <br /> APPLICANT'S SIGNATURE: C �Cf� DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/�AANAGERb OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING 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 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: <br /> COMMENTS: RECEIVE[ <br /> MAY 0 1 2006 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 3 Amount Paid I q3.C;D Payment Date I C <br /> Payment Type Invoice# Check# p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />