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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property , FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERA OR <br /> 6r, CHECK <br /> C CHECK If BILLING ADDRESS <br /> FACILITY NAME r st C ' i .. ^ <br /> SITE ADDRESS / f 1�.� D n1/V �I �L C40 <br /> Street Number Direction 77 r1J Street Name / Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #'I Ex-r . APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ai 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME (J ID ` , n Ni eD +G1 `, `Inn J PHONE # EXT. <br /> 1 j <br /> ID Y l.� CJ/ ll h 20� �`� - I 0 a �p <br /> HOME Or MAILING ADORES c / FAX # <br /> 9 � J J GWS R E)a <br /> CITY el 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, STATEand FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : M��'LDATE , /D � SJe>0 <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT EY�XJ,) A4 14 tY 5S/ A / <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 , geoteclutical 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 . P / <br /> TYPE OF SERVICE REQUESTE : 2� ` CIV/ IV T <br /> COMMENTS : P.: PICL EI V'Cirml <br /> Le V� rio ` w OCT <br /> SAN JCqQtjl <br /> HEALT ORO <br /> N DFDgRTMENTy <br /> T <br /> ACCEPTED BY : 7 %� EMPLOYEE # : DATE: ' o Z2 <br /> ASSIGNED TO : �j �i�/1tij1� EMPLOYEE # : DATE : i I Z� <br /> Date Service o pleted/ if alrea y c mpleted : ' nL SERVICE CODE : 1 Gf 7 �J P 1 E :l <br /> An <br /> Fee Amount : Sly S-cr Amount PalQ2 / D Payment Date / !D <br /> Payment Type Invoice # Check # � � /3 Received By : <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> REVISED 11 /17/2003 <br />