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SAN JOAQUI :TY ENVIRONMENTAL HEALTh TMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � s`I �� I (-)< <br /> X OWN ERIO�ERATwo / C �F� CHECK If BILLINGADDRESS� <br /> FACILITY NAME C �� � F <br /> SITE ADDRE7dt <br /> e&- t Number Direction �� �v Street me b�ii LI °ae <br /> HOME or MAILING AD ESS (If .'fferent from Site Address) <br /> NStreet Number Street Name <br /> CITY 1. O u STATE - ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LO=NCO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � CHECK If BILLING ADDRESS <br /> l�(1`14-V- v �V t/` <br /> El <br /> BUSINESS NAME PHONE# ExT' <br /> J�U�< rJvt s 'Ey VU d�� fS� 7070 <br /> OME Or MAILING ADDRESS FAX# O <br /> 'CIT) i D STATE C C 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 <br /> or 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 FEDERAL laws. GG <br /> APPLICANT'S SIGNATURE: DATE:/ r Lf -ds5 <br /> PROPERTY t BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT q a Q\r--cl—0- - L' O - <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required r V 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: C Ic_ ( Q) P�-/e- M C r O4-1 F..?C A-76 (r'F-J 4& t <br /> RUSH <br /> ACCEPTED BY: (C EMPLOYEE M C7 3 Z_/ DATE: efr`i b d <br /> ASSIGNED TO: -�_ I /' C t EMPLOYEE#: �r7� DATE: .y 1'f Qk <br /> Date Service Completed (if already completed): SERVICE CODE: /'9k PIE: p� <br /> Fee Amount: tf-7 2Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />