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! SAN JOAQU) OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> ll <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 1� <br /> \rC' -" C, 1� r�V p <br /> SITE ADDRESSZ 3 \`2-5 <br /> -Z 5 L ©vt-e_ ;v^k.2 (-1�+� S C,c�,u V\ 1 J Z G <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2.09 ) d3li3 - i�291- -;�-c-7 : `i <br /> PHONE#2 EXT• BOS DISTRICT LOCATIIACODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# p EXT. <br /> COO, 5rkO v- 2 v 9 g 3 O �U L{ <br /> HOME or MAILING ADDRESS FAX# <br /> 905 Glt7(J f— (za ) 931S tea L1 Lf <br /> CITY L S C��� $TATE r q ZIP ItF3•ZV <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,STAT i ED L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER [3 ;1 OTHER AUTHORIZED AGENT I a/'Irit( cv- O� �iC1U �ti�YYw <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 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: ��,Vs� <br /> �� <br /> yI Nry94IV Co. <br /> ACCEPTED BY: EMPLOYEE#: DATE: �Nr <br /> ASSIGNED TO: EMPLOYEE#: Z DATE: r� <br /> Date Service Completed (if alread ompleted): SERVICE CODE: �� ( PIE: <br /> Fee Amount: 5�Z.. Amount Pai l�o� Payment Date 7ec <br /> [Payment Type Invoice# Check# �Qs� Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />