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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTh )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c����� �- SAI 'V 3'Z�1� S I�(��7-7900 <br /> OWNER/OPERATOR L <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ("�/\,r/�,. •�u L^��/ r/` G/ /� <br /> SITE ADDRESS � I'�� � � ,�— <br /> / Street Number Direction S eet'Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Scree[Number Street Name <br /> CITY STATE zip <br /> PHONE Its EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE If EXT. <br /> HOME or MAILING ADDRESS FAX <br /> CITY STATE r�1 ZIP !3's-"gel <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or author' ed 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 /> 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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: v DATE: 7 //— <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 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 /> totheSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same timeIt IS provided to me or <br /> m, representative. pAYME/ y�9i�Y1 <br /> TYPE OF SERVICE REQUESTED: CV I ,J V' _ RECEIVED <br /> COMMENTS: ` _ �4 ox f n - +y017 <br /> VI ( 1 1 L(/1 ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> CCEART�"�GNT_ <br /> ACCEPTED BY: rL�/ �(� Z EMPLOYEE#: DATE: I <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: 17 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: '1 f <br /> Fee Amount: 1 C- Amount Paid Payment Date 1 f� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />