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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0— <br /> OWNER <br /> OWNER/OPERATOR 1^ �\ <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME IGc'tCPS <br /> SITE ADDRESS N. , ; r 4, <br /> .v �f <br /> L'o I Street Number I Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> U Street Number J Street Name <br /> CITY STATE zip <br /> ��n:• r C + SSC S0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (I• I4) Z13 - y �� z oar- l90 GGo -�c^v <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> N ✓lent' <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESSFAX# <br /> Gc ( ) <br /> CITYL STATE ZIP L l,�^ � . <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 lie performe ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THEIR 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 locatW the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asseation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It i i e r <br /> my representative. ' ,`rr <br /> 157111 <br /> TYPE OF SERVICE REQUESTED: AY <br /> COMMENTS: 0%,4�4TRp <br /> Ho OCON,rJny <br /> MFMT <br /> ACCEPTED BY: L(' EMPLOYEE#: DATE: _ _1 <br /> ASSIGNED TO: [ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S Z P 1 E: <br /> Fee Amount: Amount Pa' cls/ Payment Date <br /> Payment Type Invoice# Check# ISGl Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />