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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH CTEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4�a1� 5 n,�QQt e sL <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> \ OY� \A- L3 0 V�- p <br /> SITE ADDRESS y6-I N It Sib <br /> Stree[Number Direction Street NameCIN Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) M(ti- 4ep ,—k o C r\ <br /> C7 Sheet Number Street Name <br /> CITY ^ ^ IZ�Q . STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2k) f3t3f3 �9� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR T /' <br /> b 1.�L4VtC, 0 CHECK If BILLING ADDRESS <br /> BUSINESS NAME - t `I O� PHONE# ExT' <br /> Oh \ 209 08 X11 <br /> HOME Or MAILING ADDRES � qq �( FAx# <br /> (e1 )Q LJ Vr V.. t 1 (- ) <br /> CITY 12 <br /> ,1, STATE ZIP <br /> BILLING ACK OWLEDGEMENT: 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 FEo AL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER OPERAT R/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 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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: � �1 L ) E �` <br /> COMMENTS: <br /> I�`,9 D <br /> SAN 6 Z0 6 <br /> E JOAQU/ <br /> HEACTNlpO Aq <br /> cot, <br /> NTy <br /> ^ T <br /> ACCEPTED BY: EMPLOYEE#: DATE: or, _ I _ I <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: I Lo_ / <br /> Date Service Completed (ifalready completed): SERVICE CODE: PIE: , OD <br /> Fee Amount: — Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />