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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V4 V.Ok <br /> OWNER/OP T <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME (/ <br /> SITE ADDRESS ^ _ ���� <br /> Street Number Direction 3tre�t'TVame U r I ( ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY. MTE I 4 I� <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> ) ZL �� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO ; <br /> 1 C, �/�r CHECK If BILLING ADDRESS <br /> Y 1EXT. <br /> BUSINESS NAME ( PHONE# <br /> HOME or MAILING ADDREJS� c r/ FAX# ) <br /> CITY �y STATE ZIP <br /> BILLING ACKv(NOWLEDGEMENT: 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 /> 1 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, STATEa d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r 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 assess t information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is-} We or <br /> my representative. RR r4 <br /> TYPE OF SERVICE REQUESTED: , F® <br /> COMMENTS: JOA 5 �oj9 <br /> D01V C <br /> E ME��NTf. <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: n S EMPLOYEE#: ✓2 DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: 111 ' PIE`: <br /> Fee Arnount-.9 �15 Amount Pai /5�2 d'�> Payment Date <br /> Payment Type �' Invoice# Check# 2"/, Rece' ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />