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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUESTf' llllrl O� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> gemsOWNER/OPERATOR f� F Y!1 C <br /> ��� a y��,�,�!j,"! CHECK If BILLING ADDRESS <br /> FACILITY NAME s 'f <br /> SITE ADDRESS w F,-#e��„ r�x.� � <br /> Street Number Direction Street Name C t Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �i --- Street Number Street Name <br /> CITY STATE ZIP <br /> 2c) ) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> L) So '37-? <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 9rIV J-00 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR X 1 /j / <br /> ' `m - �,R,r (! �J'�J CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> O, !�1V ( ) <br /> CITY STATE -. CA ZIP .- 0� <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 /> 1 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. 1 <br /> APPLICANT'S SIGNATURE: ,�'bYj7FO U DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER A1ITHORIZED AGENT❑ Aejlzz y;-' <br /> IfAPPLICANT is not the BILLING 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 s A Is <br /> provided to me or my representative. A r <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: <br /> 1 -e v�P/tit� a l7 G(G+'j�'L SAN,1 ?O , <br /> EN�AQUIN COU <br /> NEALTH of 1Y <br /> T <br /> ACCEPTED BY: L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 07 17 <br /> 7 <br /> Date Service Completed (if already completed): SERVICE CODE: O(V ` P f : O Z <br /> Fee Amount: Amount Paid «�r r Payment Date 1 <br /> Payment Type Invoice# Check# L4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />