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SAN JOAQUI. .:OUNTY ENVIRONMENTAL HEALTI. ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � t�t�SU7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSE <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction ,StirreetName1 �� Ciitty \+ ,VZip Co'dee <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 /> (971(_) Z� & <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> V' <br /> V30"') <br /> `� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1J ' Y1 PHONE# C 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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F RAL laws. > <br /> APPLICANT'S SIGNATURE: /)7 0/0/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ A 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: CG <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> SEP 10 2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: / EMPLOYEE#: A : '.�- <br /> ASSIGNED TO: G C ( EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: -!5� P I E: <br /> Fee Amount: Amount Paid Payment Date qC v;' <br /> Payment Type Invoice# Check# (� �. Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />