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i a t i r ixx"I I 1vA1✓1'4 1 AL,A. V AL III IJEFAK I INI1i,N4 <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> � CHECK if BILLING ADDRESS El <br /> <' � . <br /> FActu-Y NAME <br /> SITE ADDRESS <br /> Street Number Direction Cit Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. API+!# LAND USE APPLICATION# <br /> c <br /> or- 0" n <br /> PHONE#2 EXT BOS DISTRICT —T <br /> OCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �? `` � I - <br /> CHECK it BILLING ADORES <br /> BUSINESS NAME r1 o.� P NE <br /> HOME or MAILING ADDRESS FAx# <br /> , c 1 <br /> CITY 6.-y-� 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 /> 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,Stan STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTI3owzEp ADEN <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh is requirld 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. - ,r <br /> TYPE OF SERVICE REQUESTED: "[ S �` L_ Ft EC��'V = <br /> COMMENTS: 4 2VUS <br /> U�N COUNTY <br /> SAN JOAONMFNTPIL <br /> ENV4RpPARE <br /> H'&Lm <br /> ACCEPTED BY: �y I� i f `J �I EMPLOYEE#: 7 L DATE:crf q- Q 9 <br /> 4 <br /> ASSIGNED T©: ° ('D Lx- EMPLOYEE#: U-77 DATE: E- ©/ <br /> Date Service Completed (if already completed): SERVICE CODE: (� P I E: �off <br /> Fee Amount: 3 Amount Paid Z 3 45'! O C) Payment Date g ! 0 <br /> Payment Type Invoice# Check# I f 37 Received By: <br /> EHD 48-02-025 SCS FORM(Golden k,d) <br /> REVISED 11117/2003 <br />