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SAN JOAQUIN -'OUNTY ENVIRONMENTAL HEALTfL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a S c� L(f 3l ��OD,1//5 <br /> OWNER/OPERATOR _ <br /> � HECI�}f ILLING ADDRESS <br /> FACILITY NAME 05JC CSr44 <br /> SITE ADDRESS V N l�� Rok �Ja!'I-SS7�J <br /> - 0 Street Number Direction Street Name Cit Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> rK1) Street Number Street Name <br /> CITY � � STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (,'/C) /I 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUEST OR <br /> REQUESTOR /// <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME U PHS(NE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY l4 4 e t1 STATE ZIP ClC <br /> BILLING KNOWLEDGEMENT: 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 aW that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandS TE and ERAL laws. � <br /> APPLICANT'S SIGNATURE: DATE: 9" L /f <br /> A*r -L o 1 l' <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: t-O O <br /> COMMENTS: �'--MDOg,,— FLLr-jVED <br /> SEP � c) 2o:19 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: O L C ULC f EMPLOYEE#: (r,)3 L DATE: g 3 D l/O <br /> ASSIGNED TO: EMPLOYEE#: r A DATE: G} &ID /p <br /> Date Service Completed (if already completed): SERVICE CODE:/S 2_2PIE: i&O <br /> Fee Amount: 3�� Amount Paid 3 L Payment Date 3 ( b <br /> Payment Type ✓ Invoice# Check# 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />