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i <br /> } SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 007 f <br /> OWIER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME [ {may <br /> SITEADDRESS �► -72� W / { ,rt+/ <br /> Street <br /> Number rtian l./ /Y qf—f Name�C•_ <br /> HOME Or MAILING ADDRESS (if Different from Site Andress) <br /> Street Number Street Name 1`�Ig cn <br /> CITY STATE zip C <br /> PHONE#1 EXt'' APN#✓: LAND USE APPLICATION# D <br /> PHONE#2 EXT. BOS DISTRICT LOC Q <br /> CONTRACTOR I SERVICE REQUESTOR MFM <br /> REQUESTOR + <br /> CHECK If BILLING ADDRESS <br /> Tt Cj <br /> BUSINEss NAME PHONE# EXT. <br /> 7 2l� oo� <br /> HOME or MAILING ADDRESS FAX# <br /> 1 <br /> CITY STATE CiA- 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 or <br /> activity will be billedto me or my business as identified on this form. <br /> I also certify that I have prepared this applica' n and that the work o p ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT d FEDERAL la <br /> APPLICANT'S SIGNATURE: t DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN ER d 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 /> F 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 /> 1 my representative. <br /> TYPE OF SERVICE REQUESTED: i� l <br /> COMMENTS: <br /> will be e-r7yC4 k%-? -W C r ud U,&"f- <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: v� EMPLOYEE#: DATE: r 2Z <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> f Z <br /> Fee Amount: Amount Pai't��R7�2� Payment Date g l <br /> Payment Type(?I I Invoice# Che g# � 022_7.—a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> r <br /> k , <br />