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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />�e( el / _ , %� <br />����� <br />% <br />4SqN ?0% <br />CHECK If BILLING ADDRESS <br />FACILITY NAME j <br />8 ✓py <br />SITE ADDREESSS�/��/, <br />3(� Street Number <br />Direction <br />n �� <br />" - u� / , " _Street N me <br />L <br />Ci <br />RTMF�T <br />Zip Code <br />HOME or MAILING ADDRESS �(If Different from Site Address) <br />Street Number <br />7 <br />v1 �'Street Name <br />CITYZ—Oxq/ <br />STATE� <br />ZIP <br />S <br />PHONE #1 -Exr77 <br />(a�> 33�-03(0 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />Fee Amount: <br />LOCATION CODE <br />/CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j1 / /1'. , r (' CHECK If BILLING ADDRESS <br />BUSINESS NAME (,�, , N PNp 2 CTO EXT. <br />HOME Or MAILING ADDRESS LU /� � FAX # ) <br />CITY �N%. /f 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 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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandardsaSand �FfEDE la /�J <br />APPLICANT'S SIGNATURE:'/- DATE: / /u <br />PROPERTY / BUSINESS OWNER 2S 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 assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is pr Q me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: �JN (� W'1 ieS�1 <br />427:le(-S <br />COMMENTS: <br />% <br />4SqN ?0% <br />8 ✓py <br />F� 71kR�' <br />RTMF�T <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: ' L� <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: I <br />Fee Amount: <br />Amount Paid <br />'` JCS ✓�I,� <br />Payment Date <br />l <br />Payment Type <br />Invoice # <br />Check # �; S ? / <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />