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SAN JOAQUIN )LINTY ENVIRONMENTAL HEALTH 1 ARTMENT <br /> SERVICE REQUEST <br /> Ty a r <br /> us ess or Prope FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS F, � Tk Sr. �vzt� �y CtS3-7 <br /> 1Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i T Street Number Street Name <br /> CITY TATE ZIP <br /> c <br /> PHONE#1 ExT APIN# LAND USE APPLICATION# <br /> ( <br /> )VI) - q 9 tA <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# 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 app[' ation and that e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard , T T and FED laws. I� <br /> APPLICANT'S SIGNATURE: DATE: ' V 4Cf— <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 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: Ctiy( D <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED OCT 2 9 2012 <br /> OCT 21 2012 <br /> SAN JOAQUIN COUNTY ENVIRONMENTALH LTH <br /> N TH DEPARTlIE11T DATE: /�(� / <br /> ACCEPTED BY: EMPLOYEEiF: — t G <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: &- �-- P 1 E: a <br /> Fee Amount: Amount Paid ),� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> L <br /> EHD 48-02-025 qSR FORM Rod C ) <br /> REVISED 11/17/2003 <br />