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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 09'A'I -vF; cc-I����� <br /> OWNER/OPERATOR S CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME.-f/��j I�[ ��i �n�r) �� I i <br /> SIT DDRESS <br /> ? rl � <br /> Street Number Direction lA"Street Name CI V' ZI ode <br /> HOME 0 AILING ADDRESS (If Different from Site Address) , <br /> �j i � <br /> S• ��U Street Number Street Name � � <br /> CITY n i (1 k—" [4 STATE ZIP <br /> PHONE#1 '^ �n E.T. APN# LAND USE APPLICATION# <br /> ocft 040• W vim' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR j �� <br /> 11,4 ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME Y! LJ� I�j 1( A I/�j��J^'1 �/��Q�/ f) PHONE# ^64 , EXT. <br /> HOME or MAILING ADDRESS 16 / ) FAX# fT <br /> A <br /> CITY Q It 01,i ^/\_ 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan STATE�F�,EDERAI'13 � <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/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 loc� at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ass f rmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It�� Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> n j \S <br /> /y, <br /> aO,q�IiO�i C 18 <br /> N pFpq�H�,yry <br /> MFNr <br /> ACCEPTED BY: CmA�',/�S C_E) EMPLOYEE#: DATE: / / <br /> ASSIGNED TO: �`--�yCC�t�tt I—v o EMPLOYEE#: DATE: . C lbJ/ <br /> Date Service Completed (if already completed): SERVICE CODE: O/; P E: )� <br /> Fee Amount: ��� �� Amount Paid �5�60 Payment Date <br /> Payment Type Invoice# Check# � � D Receiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />