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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C !�S STAT 10 � <br /> Pp, moi' S <br /> OWNER/OPERATOR _ <br /> L0 V S 1 CHECK if BILLING ADDRESS <br /> FACILITY NAME i <br /> Ln VES N•7- _S I o V, <br /> SITE ADDRESS 11-; 93 �--C: Cof o � t V b t-� CA . a 3 (C. <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (',( <br /> p. 0 /, 2 YJ �J Street Number Street Name <br /> CITY STATE ZIP <br /> QAK L-A r40 t2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,. <br /> KF 1 f-1 \ I ' ^ a C, CHECK If BILLING ADDRESS El <br /> BUSINESS NAME V�I t t 1� PHONE# ExT. <br /> �i A �ti � 1�I L ' 16. <br /> HOME or MAILING ADDRESS , FAX# <br /> CITY -D l X c� _ r STATE ZIP <br /> UA <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 /> 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,STS E and FEDERAL laws. <br /> APPLICANT'S SIGNATURTs-- �_----- DATE: <br /> L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C <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 <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE. <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 .SR FOF1M(Golden Rod) <br /> REVISED 11/17/2003 <br />