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r - _ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ;�� ^ � " <br /> CYJ` /LJ' P e CWCK if B+Lu,+c ADORE,ss <br /> FACILITY NAME G <br /> SITE ADDRESS ^ ^ <br /> . � ���1 v� � 1-civ ���.��� �(�;w c <br /> ShMt Ny h <br /> HOME Or MAILING ADDRESS (If Different from Site Address) p 0_/ <br /> /lsa .wN„rrA„ Ily, 00M✓�u <br /> CITY In .i ZIP <br /> /ViiZ r7 <br /> EXT. APN 0 LAND USE APPLtCATt0N <br /> PHONE 02 EXT. BOS DtSTRICT t ocATaN COM <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> / REQUESTOR em den CHECK if BuiNG ADDRESS❑ <br /> S <br /> BUSINESS N Ei En. <br /> —)too() <br /> HOMEor M G DDR S* e FAX t <br /> Y ( } <br /> CITY / STATE Zip <br /> V 7 Q > <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized aged of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated %%!th this project OT <br /> activity Will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appli tion n that thew rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TA and ERAL 1 <br /> XAPPLICANTS SIGNATURE: - DATE:: DD <br /> / \PROPERTY 1 BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT t� <br /> IfAPPLICANT is not the BILLING PARTY.Proof of authorization t0 sign Is required Tiflt <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 environmentalisite 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. <br /> TYPE OF SERVICE REQUESTED: ^,` r <br /> COMMENTS: V�® <br /> sAN�gR o� ?ot <br /> NFA �Og4cl� 9 <br /> [T NMEN (JN <br /> ACCEPTED BY; EMPLOYEE#: DATE: 744 it <br /> NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: D,I PIE /Gam <br /> Fee Amount: S — Amount Pal /s�� �� Payment Date <br /> Payment Type Invoice# Check# 73s— Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />