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SAN JOAQi COUNTY ENVIRONMENTAL HEAL7%.,;)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY:ID# SERVICE REQUEST# <br /> It OC> <br /> OWNER I OPERATOR A C HFCK if BILLING ADDRESS❑ <br /> FACILITY NAME '/�,� v M u•Az v <br /> SITE ADDRESS CIi/•` e r <br /> Street Numher Direction Street Name J Ci Zi Cod <br /> ROME or MAILING ADDRESS (If Different from Site Address) O� L N . A(r p DV-� <br /> r Street Number Street Name <br /> CITY rljf STATE zip <br /> Err. L , APN# LAND USE APPLICATION# J <br /> PHOI0 -1- 11- o� <br /> PHONE#2 Exr• BOS DISTRICTO LOCAT10 ODE <br /> ) 6 o 0311 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR 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 application and tha ork to be performed will be done in accor nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TA EDERAL laW . <br /> APPLICANT'S SIGNATURE DATE: 0 <br /> I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ OTHERAUTHORIZEA AGENT❑ <br /> IfAPPLicANT is not theB1LLINGPARTY 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: <br /> COMMENTS: w � A-u-&�- zot 4, 1-c. MYME <br /> V"•LLA- �� IIS V, A*..c- I,"- o+.frlrW RECEIVED <br /> 00082014 <br /> SAN JOAOUI FNVIQOM�OUNrf <br /> ACCEPTED BY: EMPLOYEE#: DAA <br /> ASSIGNED TO: EMPLOYEE I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: fl P!E: O <br /> Fee Amount: 1 30 Amount Paid -5 F Payment Date NV11'3 <br /> Payment Type Invoice# Check# Received By: L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />