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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/OPERATOR /j <br /> r% E P, /�h Z) 1-i -A j� CHECK If BILLING ADDRESS <br /> FACILITY NAME J III <br /> SITE ADDRESS <br /> 1 I Street Number I Direction V V Street Name City Zio Code <br /> HOME Or MAILING ADDRESS (If Differet from Site Address) 7) <br /> (J �UI -� ✓ Street Number Street Name <br /> CITY STATE ZIP <br /> 41 - 3 1!5� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (29) - ,611O - 1 Z6 y Z 2`3-( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' CHECK If BILLING ADDR <br /> i BUSINESS NAME / l PHONE# C <br /> HOME or MAILING ADDRESS (� _ FAX# O <br /> �(s c ) CT ?018 <br /> CITY STATE ZIP �OAQUf(y <br /> U <br /> BILLING OWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agfs <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this�proje TMEjyT <br /> activity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the wor to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S1 -2 nATE and FEDERAL;Vll-� <br /> APPLICANT'S SIGNATURE: ! DATE: IIS l I -2-Z7 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR f 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, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AA (2-6q) <br /> A 4- 1 H-d LfSvs�.e� i s V1f �j <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: L7 if/ 10 <br /> Date Service Completed (if already completed): SERVICE CODE: P") / P I EZ:P7 <br /> Fee Amount. ,'� Amount Pa � �� Payment Date <br /> Payment Type Invoice# Check# <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />