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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S VICE REQUEST# <br /> 5 0NZ61IT <br /> OWNER I OPERATOR <br /> 1 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME 'F <br /> l� oC T ,•Ca <br /> SITEADDRESS fqon5 <br /> 54 Sz�* <br /> (( Nmbdq I <br /> ' ` <br /> Street Name city ZID Code <br /> HOME Or MAILING ADDRESS (If Different l{frrom Site Address) <br /> W F f L Py,h Street Number Street Name <br /> CITY TO G STATE ZIP C^� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (2� 1 2G 3G <br /> PHONE#2 EXT. BQS DISTRICT LOCATION CODE <br /> ( ) SeZ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> (' CHECK If BILLING ADDRESS <br /> BUSINESS NAME (�Iate. S `IC CA K A PHONE# _�Q'G ExT. <br /> HOME or MAILING ADDRESS FA%# S <br /> t ( 1 <br /> CITY C I _ C I- STATE h zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 laws. 77 � <br /> APPLICANT'S SIGNATURE: &-W-P-1 C)e)kIW_ C• DATE: T ��f / y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[3 <br /> If APPLICANT i5 not the BILLING PART) (Hoof Of authorization f0 Sign i3 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 assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It i5 available and�YL 1C Afe It 15 <br /> provided tD me or my representative. // s$('L`/V <br /> TYPE OF SERVICE REQUESTED: Ci'� w G 2 <br /> COMMENTS: ENV AAQIJ <br /> N�Tyo pME O�7Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( ( EMPLOYEE#: ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Q f <br /> Fee Amount: 100 1Amount Pa60 Payment Date <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />