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SAN JOAQ .4 COUNTY ENVIRONMENTAL HEAL_ DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1�2 O'D �3 v <br /> w1tn.:E L <br /> OWN R/OPE TOR ,+ <br /> ICHECK It BILLING ADDRESS <br /> FACILITY NAME I ( � r' <br /> SITE ADDRESS ` C 1 Oor a <br /> Street Number Direction Street Name \Clt Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) _1 335 �{ C �I E y �3?- <br /> Street Number Nme <br /> CITY sfe L STATE ZIP 9 -5 <br /> PHONE#t v U EXT. APN# LAND USE APPLICATION# <br /> t2U 1229 ?25o 12-- <br /> PHONE X13 2 (7Z EXT, BOS DISTRICT LOCATION CODE <br /> r 01 - � IL <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 <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,Standa ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 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 <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 Sy <br /> the same time it is <br /> provided to me or my representative. EN <br /> TYPE OF SERVICE REQUESTED: HECELVED <br /> COMMENTS: UUT 0 4 2013 <br /> Crk�t�� S SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH I1f PARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: L) 1 <br /> ASSIGNED TO: 7�� EMPLOYEE#: DATE: / <br /> Date Service Completed (if already Completed): SERVICE CODE:,-' f ' i PIE: (GO2_ <br /> Fee Amount: L Amount Paid ;dD Payment Date Ib <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />