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SAN JOAQUI.. .'OUNTY ENVIRONMENTAL HEALTH _..:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK P BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J!` -7v C 7 �1 � I�j 1 /4Q /ZX(�7T d.) !✓��b <br /> Sheet Number I Direction Street Name city Zip Code <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 /> ( ) ( L- ,-( -22C '— If <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� <br /> /� �'�� �v 11��('� CHECK if BILLING ADDRESS <br /> BUSINESS NAM' ` ���lll as PH NE# ExT. <br /> HOME Or MAILING ADDRE FAx <br /> �7 Z !S 74 <br /> CITY I t j�.l !{ ,An —S� 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 1 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 FEDERALs I <br /> Z 7-� <br /> APPLICANT'S SIGNATURE: DATE: -���y�,,� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 1:1 OTHER AUTHORIZED AGENT Cty/ %*C7& - <br /> IfAPPLICANT is not the BILLING PARTY.proof of authorization to sign is require 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 t0 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: (� S � t)F—t 1 R MEN <br /> COMMENTS: <br /> FEB <br /> 82008 <br /> SA N�OAQUIIV C <br /> HF�TN p�AIE 7 t Ty, <br /> ACCEPTED BY: (�� I S EMPLOYEE#: 0 Z,J DATE: o <br /> ASSIGNED TO: C EMPLOYEE#: DATE: 2 <br /> Date Service Completed ( already completed): SERVICE CODE: 4 P 1 E: <br /> Fee Amount:-V Amount Paid 14, 6D I Payment Date Z Ug <br /> Payment Type v S 4Invoice# e t"t # 6 2 Received By: W--r- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />