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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�A f� 7A <br />FACILITY ID # <br />EXT. <br />SERVICE REQUEST # <br />OWNER/OPERATOR f`_a ` <br />/ <br />CHECK If BILLING ADDRESS <br />^ <br />FACILITY NAME <br />lv9L [/ <br />CITY STATE ZIP <br />SITE ADDRESS <br />Street NJmberDirection <br />DATE: <br />Street Name <br />SERVICE CODE: <br />HOME or MAILING -AD ESS (If Q nt from Site Address) <br />Street Number <br />Fee Amount: <br />Street Name <br />CITY <br />$TATE= zip <br />PHONE # E-./APN <br /># <br />LANb USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR�j/ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />EXT. <br />COMMENTS: <br />aAN — 3 Z�14 <br />SAN jAQUIN COUNTY <br />- N'4IROHMENTAL <br />ACCEPTED BY: <br />HOME or MAILING ADDRESS <br />Fn# ) - <br />CITY STATE 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 Or <br />activity will be billed to me or my busi ess as identified on this form. <br />I also certify that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDERAL laws. J ,} <br />APPLICANT'S SIGNATURE: l DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICAN 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 to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />aAN — 3 Z�14 <br />SAN jAQUIN COUNTY <br />- N'4IROHMENTAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />ATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />R ceiv d By: <br />EHD 48-02-025 SR FORM Golden Rod) <br />07!17!08 <br />!-3 <br />