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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business orr7opert FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FAciuw NAME r ilk <br /> SITE ADDRESS t) U F <br /> street Name Zip Code <br /> q <br /> ( t1t <br /> HOME or-MAILING ADDREPS (if Ilifferent from Site Adclre-�si% <br /> I?!-A L d&��f <br /> CITY Z-o STATE ZIP Sr�yo <br /> FHW"#1 P NPN 0 LAND USE APPLICATION# <br /> (gl-qg) -3 e,94 <br /> EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR CHECK it @ILLING AooBEss 0 <br /> BusittEss NAME- <br /> e-e_ 3- <br /> HOME or MAILING ADDRESS FAx# <br /> 12 - - e <br /> '0' <br /> X <br /> CITY STATE r A ZIP y -5p <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 ENVIRONT41ENTAL I-Ir-ALTIt 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 FIDERAL laws. <br /> APPLICANT'S SIGNATURE: "P 21 DATE: <br /> PROPERTY/BUSINESS 01V.-,'ER13 OPERATOR/M.104AGER❑ OTHER AuTHoRIZED AGENT <br /> If,4PPIJ",Vristiatlire BiLlIN-GP.4g proof of authorization to sign is required rifle <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 enviromnentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL,rH DFPARTMFW as soon as it is available and at the same time it is <br /> provided to Inc or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: T/V',KTO" <br /> ACCEPTED BY: EMPLOYEE#: DATE: -07111a <br /> ASSIGNED To: EMPLOYEE#: 6 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Ftecelved By: <br /> A--— <br /> EHO 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 1111712003 <br />