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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> olcg li a 39q <br /> OWNER I OPERATOR !jR �rClK (. f ��1t"f JO2't <br /> I� CHECK If BILLING ADDRESS <br /> FACILITY DAME I o��!�7 ✓ t,y <br /> SITEADDRESS 'r2vttC_ <br /> Street Number Direction Street Name Zip Code <br /> HOME or MAiLINo ADDREssk A - /(if Different from Site Address) <br /> �� '[C a Street Number streetName <br /> CITY {?4 W04A STATE - Zip -7 �� Z <br /> PHONE#1 EXT- -TPN# 1-75-1-7C) l O j—1 LAND USE APPLICATION# <br /> ( F/7) L1/5 (,`35-7l`7S=J U of <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTC)R <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHOy/NftE__# Exr, <br /> f iF/ <br /> HOME Or MAILING ADDRESS <br /> 7d Win <br /> 15�GS <br /> CITY�� STATE /'A ZIP G} 23 <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 /> I also certify that I have prepared this application and that the work to be perfvrrtted will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEM- laws. <br /> APPLICANT'S SIGNATURE: / '/ � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT <br /> Tf APPLICANT is not the BILLING PARTY proof of authorization to sigrr is required T1t1 e <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 ENviRONMrNTAL HEALTHDEPARTMENTas soonas it is available and at the same time it is <br /> provided to me or my representative. PAY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A �6 <br /> t <br /> SA eN OEP �i�I C <br /> AccePTEo BY: r EMPLOYEE#: LC � DATE: <br /> ASSIGNED TO: t, �. EMPLOYEE#; V,t ,gDATE: IZ/./ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: tt qv 7 <br /> Fee Amount: Amount Paid -'S, 7)-DPayment Date <br /> Payment Type Invoice# Check# Reoelvt3 By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> I <br /> 1 <br /> I _ <br />