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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> es w�k (-Pro 0 00 u F <br /> �oO <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> C 1 <br /> FACILITY NAME <br /> a e b �� I <br /> SITEADDRESS <br /> Street Number Direction 1 Street Name city Zip Code <br /> HOMEr AILING ADDRESS (If Different from Site Address) u'( s p U olc ,pi. <br /> f Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#'l +A^ Ems. APN# LAND USE APPLICATION# <br /> (Z, ) u'; q <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS <br /> C � <br /> BUSINESS NAME � II PHONE# Ems' <br /> A o✓,niul0701 1 <br /> HOME or MAILING ADDRESS FAX# <br /> Cm STATE Zip G,S'�� <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. X�77 <br /> APPLICANT'S SIGNATURE: 4" DATE: b� Z/4 Zz 7 <br /> PROPERTY/BUSINESS OWNEM OPERATOR/MANAGER ❑ OTHER 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, 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 envirbnmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it Is available and at the s te� jt is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> E� 0 PMR N <br /> ACCEPTED BY: CCLJ3 EMPLOYEE M 1�7r-3�8DATE: Z f 24 23 <br /> ASSIGNED TO: i1,R f-mnLHZ, EMPLOYEE#: IDK1 DATE: 2 -11�J I Z7 <br /> Date Service Completed (if already completed): SERVICE CODE: P 'EMI�pOZ <br /> Fee Amount: I' Amount Paid 1(� -- Payment Date 2 2t <br /> Payment TypeeajInvoice# eck fi5 L} Received By:uv <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> peo1�3230 <br />