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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type o usiness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> H4,0- <br /> FACILITY NAME <br /> j4rcn <br /> SITE ADDRESS411 V1 <br /> 1, <br /> Street Number Direction Street NamE Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> QStreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �LL1G <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS r FAX# <br /> CITYL /__ _ , STATIC ZIP 95 <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 TATE and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE E DATE: —V <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C1.�Kild <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 environmentaUsite 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: A vEU <br /> COMMENTS: �0p8 <br /> JAN 2 <br /> 1N GOVNN <br /> SP ENS Ro EPPRZM�I3T <br /> NFAIIN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( t J EMPLOYEE#: 7J„� DATE: <br /> Date Service Completed (if already Complete : SERVICE CODE: '-'lam PI E: ts <br /> Fee Amount: �� Amount Paid �f�4 `6� Payment ate L 2 �' <br /> Payment Type Invoice# Check# 12573 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />