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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A-� S7ic1 <br />FACILITY ID # <br />PA baa 3i <br />PHON # EXT. <br />SERVICE REQUEST # <br />std Cr -O 69 7S <br />OWNER /OPERATOR 1��7 <br />/ /_ t P <br />CITY w STATE ZIP <br />CHECK if BILLING ADDRESS O <br />FACILITY NAME A- - �_ /� J� (- 6 <br />(-� <br />jf4� <br />ASSIGNED TO: <br />SITE ADDRESS -7 <br />EMPLOYEE #: <br />0 � Af -( t RIP`ZA <br />� <br />&37 <br />Street Number <br />Direction <br />Fee Amount: <br />Street Name <br />Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />Received By: <br />/lam <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />90 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 t/ EXT. <br />( C//V? <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ^ /1A <br />EJ;CHECK If BILLING ADDRESS <br />BUSINESS NAME �q� j /�' r�,.� !� d �-- �i <br />1r{'u✓ U(/T, l <br />PHON # EXT. <br />HOME or MAILING ADDRESS <br />FAx <br />CITY w 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 business as identified on this form. <br />also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd FEDERAL.Is- <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 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, 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 a5 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 />N t n <br />COMMENTS: <br />Ji7- <br />4<5-0 4 & <br />-// / '�L <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />