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SAN JOAQUtty COUNTY ENVIRONMENTAL HEALTH NPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OCTi5� <br /> OWNER I OPERATOR <br /> C A � i CHECK If BILLING ADDRESS <br /> FACILITY NAME J� V \ f�/ <br /> r�? makK <br /> SITE ADDRESS �/ / <br /> t t//LL� L<j �S2C�LI <br /> Street Number Direction d\t � Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY G / D 1^ �C-\ STATE ZI s� o ! ' <br /> PHONE#1 \ EXT. APN# LAND USE APPLICATION# V <br /> (Ar Y �0, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME - PHONE# EXT. <br /> i <br /> L - IVA n kt .ssy' 6 2 2 <br /> HOME or MAILING ADDRESS {{ FAX# _ <br /> CITY - — U STATE ZIP �) r✓ i <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, ATE and F ERAL WS. <br /> APPLICANT'S SIGNATURE: DATE: 6 ` <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 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 pfQVlded t0 me Or <br /> my representative. �'<•- <br /> ,4. <br /> TYPE OF SERVICE REQUESTED: i <br /> COMMENTS:I vjQUI/ <br /> H� NlR0.4 ANO''V�Y <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: )zf 11-7 <br /> ASSIGNED TO: / EMPLOYEE#: DATE: V1 <br /> Date Service Completed (if already completed): SERVICE CODE: / P1E: <br /> i <br /> Fee Amount: s Amount Paid Payment Da e <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />