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^"N r-,% <br /> SAN JOAQUIINN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1l <br /> OWNER I OPERATOR / P N A I N I <br /> CHECK If BSLLSNG ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS I O <br /> Street Number Direction Street Name Cit Zi Code �� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. $OS DISTRICT LOCATION CODE <br /> ( a o S:-- 11 7ra <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADO RESS <br /> BUSINESS NAME PHONE# FXT. <br /> HOME or MAILING ADDRESS FAX# <br /> � <br /> ClrY M� 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 Luc 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. <br /> APPLICANT'S SIGNATURE: — --�-- DATE: <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER OTHER AUTHORIZEnAGEN i <br /> IfAPPLiCANT is not the BILLING PARTY,proof of authorization to sign is required rifle <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: aipd <br /> COMMENTS: +� 11 l �1 nEP Ve6 <br /> V SqN JJoq 11 1014 <br /> yeA�Nvt1)ASR A1. <br /> `,, rME <br /> ACCEPTED BY: /y�J,/y _ EMPLOYEE#: OATE: r r <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: Z P!E: ,[� d / <br /> Fee Amount: )? d r— Amount Pafr�' 330.ODPayment Date ��l <br /> Payment Type ✓ Invoice# Check# Received%y <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />