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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACT TY ID# SERVICE REQUEST# <br /> OL' ly <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY DAME <br /> 4 ' '1 S ���T <br /> SITE ADDRESS &zjT <br /> c rr L 9S z� <br /> et Number Direction b Street Name S Cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ( L <br /> S Street Nvmber �. ���4reet tfame Y <br /> CITY STATE zip <br /> v C C 4 iJr <br /> PHONE#t EXT. API# LAND USE APPLICATION# <br /> (Z° y -� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S- W-k <br /> CHECK if BILLING ADDRESS O <br /> BUSINESS NAME PHONE# EXT. <br /> ( 1 <br /> HOME or MAILING ADDRESS FAx# <br /> ( 1 <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 <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, TE and FEDERAL la <br /> PPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNERO PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ fj e,� �-� <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 sante time it is <br /> provided to=or my representative. <br /> TYPE OF SERVICE REQUESTED: MIX , OSOL&fionqY <br /> COMMENTS: CJ111 <br /> a( V [(11 OAv mool 8AN Jo Z02 <br /> ate` �Ar IRQUIIV CouL <br /> 4 NM�Nrp <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 f <br /> ASSIGNED TO: EMPLOYEE{#: 5 DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Paid a r/' Payment Date �2f <br /> Payment Type Cho I Invoice# E;he Received By: <br /> U <br /> D <br /> RHD 025 �i 5R FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 � <br /> 1/17/2003 - _ � !'l <br />