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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 BILLINGADDRESSE] <br /> FACILITY NAME 111 <br /> SITE ADDRESS 2-1 <br /> LA N M OL,%Y) 5 M A V4f—C Q <br /> Street Number I Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from`SitLe Adrld�ress <br /> ISTIP V S. HJT' ' ` Street Number Street Name <br /> CITY STATE ZIP <br /> ar>` C 4", 1 S�3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (40S) 15 15 1 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /// <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME \\ \ _ _ PHONE# y EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �v\ STATE L CJ ZIP q 5 33T <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 FEDERAL laws. G <br /> APPLICANT'S SIGNATURE: DATE: S I <br /> PROPERTY/BUSINESS OWNER O RAT R/MANAGER El OTHER AUTHORIZED AGENT ❑ <br /> /f faPPLICANT Tsnot the B LING ARTY,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 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 provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> MAY 08201 <br /> SAN JOAQUIN COU TY <br /> ENVIRDEPARTM NT <br /> HEALTH <br /> ACCEPTED BY: �'�� . 1 EMPLOYEE#: DATE: ` <br /> ASSIGNED TO: ^ 'n L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed : SERVICE CODE: 1:7D- <br /> z'?1) P E: <br /> Fee Amount: i y;. Amount Paid �( 1 Payment Date l <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 j�1 t 4 SR FORM(Golden Rod) <br /> 07/17/08 <br />