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• <br />SAN JOAQUIN 11UNTY ENVIRONMENTAL HEALTH rs-PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />c \ -). s • CC - •-...) k.k,. \ \'‘,.-, <br />FACILITY ID # SERVICE REQUEST # <br />_ -4r 60 <br />01kNER / OPERAT-6 <br />L‘ rdo Lk, u. QX) <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Sig ADDRESS <br />'ç \ Street Number Direction \ '\(\,'\ C <br />Street Name SCC 1 QOM- n k), Zip .ode <br />: HOME Or MAILING ADDRESS (If Different from Site Address) <br />VAS 1 1Q.....4;LAZCIL k.P.....\)0,84.cx \.6-skAA Street Number Street Name <br />CITY t ) STATE ZIP <br />. PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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 or <br />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 ERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER Fr <br /> <br />OPERATOR / MANAGER 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />lock <br />Title <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <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 />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 70t) Vekt I CL^ rim/(,Lvscrrop,,j, EiNa ppitli ,--. <br />COMMENTS: RECEIVEU <br />IA. C-- 14- .-i--1-4 5 23 1 <br />FEB 2 5 2511 <br />ts, couNv <br />c_p,,,, JoixQuitsAEN-Tp4-.,,_ <br />- ENvIRDN ...-rviErl 1 <br />HEAL:CI-A C'EP <br />ACCEPTED By: .----- EMPLOYEE #: 4•1;10 DATE: <br />2 07 0 ( <br />ASSIGNED TO: PEDFA•Zack <br />EMPLOYEE #: ec t 'I <br />. <br />DATE. <br />Date Service Completed (if already completed): SERVICE CODE: 64 PIE: /60g <br />Fee Amount: („S tac, t"."- Amount Paid \ L) ''. --- Payment D e 2 ( 2-S / O (- <br />Payment Type c.,._32 Invoice # Check # --- Received By: W.-- <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003