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0 <br /> SAN JOAQUT COUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> 112200007 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> V 4�K&F— CHECK if BILLING ADDRESS E] <br /> Tom' <br /> FACILITY NAME <br /> SITE ADDRESS 514-7<- v4,- Ad.l-E✓aLtZ <br /> Street Number 1 Direction Street Name city Zio 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 /> ( ) <br /> /d ?- 27c> -A6 r13 <br /> PHONE#2 EXT. BOS DISTRICT (, LOCATION CO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> r (]� CHECK if BILLING ADDRESS X <br /> BUSINESS NAME (1`'Iv - PHONNE# Ear <br /> `/• 1°� ( 331-1 <br /> 3 <br /> HOME Or MAILING ADDRESS FAx# <br /> o X (Zo9 ) 3�r�� 07 Z-17 <br /> CITY L Oil) STATE �i4- 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, STATE and FEDERAL laws. l <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT❑ <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: <br /> s IIAAi l <br /> kVl I QU/Iy <br /> y�CTH114 q TAS <br /> ACCEPTED BY: EMPLOYEE#: —s DATE: f <br /> ASSIGNED TO: EMPLOYEE#: vv-7 DATE: <br /> c <br /> Date Service Completed (if already comple ed): SERVICE CODE: —2 5 P i E: <br /> Fee Amount: Amount Paid 30��� Payment Date /I4 2— <br /> Paymgnt Type �i Invoice# Check# 2213 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />