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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property. FACILITY ID# SERYI CE REQUEST# <br /> OWNER/OPERATOR ) Y <br /> ll /6?�/•jam;)� ���J a-0CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Stmt Numb r I Direction reef N�e CC7it �Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site,Address) <br /> Gl:s6A7� Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> CT <br /> PHONE W2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME _ PHONE# ExT. <br /> o <br /> HOME Or MAILING AD RISS, � G ,� � FAX# ) <br /> CITY(/ STATE ZIP C� J <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, Standards, STATE and FED ga}laws. <br /> APPLICANT'S SIGNATURE: ---- 'C 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 Tit I'P YA4,MT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property loca <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess i <br /> t0 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. JAN 1 1a <br /> TYPE OF SERVICE REQUESTED: I. S <br /> COMMENTS: �� r l ' r. R T�� (�_ <br /> TC !tNVIR <br /> q T <br /> s e-- i64-C ;vkc� <br /> ACCEPTED BY: EMPLOYEE#: DATE: Y I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (ifa4adycompleted): SERVICE CODE: <br /> Fee Amount: r Amount Paid 11�' 5�_, D U Payment Date I <br /> Payment Type �1 Invoice# Check# 14 3 �Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />