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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Num er Direction 1 r Street Name Ctt l Zi 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 /> (,gol �' <br /> 34 -4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> S�l S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ,& CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH NE# EXT. <br /> 32 3 <br /> HOME or MAILING ADDRESS FAX# <br /> 55-31 <br /> ( ) <br /> CITY SATE ZIP e� <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 EDERAL I s. <br /> APPLICANT'S SIGNATURE: DATE: /%4/ <br /> PROPERTY/BUSINESS OWNER LY! OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tirfe <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 environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is pPAYMENT <br /> my representative. "Y 1 <br /> RECEIV <br /> TYPE OF SERVICE REQUESTED: f, <br /> COMMENTS: }� 11.I i 'Is^er4iv n . APR 0 1 20'9 <br /> �J w• 1 SAN JOAQUIN COL NTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /�1 A r EMPLOYEE#: Q-2 DATE: <br /> ASSIGNED TO: I Vl 1� EMPLOYEE#: ��O�jJ a DATE: i <br /> Date Service Completed (if already completed): SERVICE CODED: P/E:I/I no� <br /> Fee Amount: 'rJ" Q Amount Paid �L Payment Date / �v <br /> Payment Type Invoice# ,6heck# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �d� � �� 0 <br />