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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> t <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 2"A b1i Street Number Direction Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BIDS DISTRICTLOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR -Fa'-c fray <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEC k-'s <br /> / ^�h_ PNpNE# ExT. <br /> HOME or MAILING ADDRESSs FAX# <br /> 7L t ( ) <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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,S an IFEDEtw laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT/ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sign is required w 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. PA3 <br /> TYPE FAMEQttITED: I_'VED <br /> COMMCj f <br /> SUN 0 2 2417 ��tot o .� (n .1�:� �; 1. 2417 <br /> SAN JOAQUIN COUNTY <br /> SAN JOAQUIN COUNTY_ ENVIRONMENTAL <br /> EI'MRONMENTMEi�IT ViEALTI'1 DEPARTMENT. <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ /-7 <br /> ASSIGNED TO: EMPLOYEE M DATE: r I <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: y 1'7-- Amount Paid (rt t Payment Date G 7 <br /> Payment Type C Invoice# Check# Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />