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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR I( <br /> CHECK If BILLING ADDRESS <br /> 0 <br /> FACILITY NAMElI i{C,�s(A C L11 S/ ,1 _-7, <br /> SITE ADDRESS c� / � /� �� <br /> Street Number Direction Street ame I city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Jop 93 — '70fl y <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CO E <br /> L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 �i�) I CHECK If BILLING ADDRESS <br /> Nj x) v <br /> BUSINESS NF PHNEE, EXT. <br /> � 5 L �S X15 �r i. �- 0 8 S <br /> HOME or MAIL ADDRESS 17 <br /> Is 'e i FAx# <br /> '— ( ) <br /> CITY 1{ 4(,,,o e STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: x DATE: O I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT is not the BILLING PARTY,pro of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When pplicable, 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Foo CQfi5(tl�a7� 01 <br /> COMMENTS: <br /> C�10ri�� <br /> ACCEPTED BY: l EMPLOYEE#: DATE: n <br /> ASSIGNED TO: r�r�. 'C' EMPLOYEE#: DATE: <br /> Date Service Completed (if already co leted): SERVICE CODE: �1 � PI E: C� <br /> Fee Amount: Amount Paid I Payment Date 8 <br /> Payment Type Invoice# ck S�O >I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />