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I SAN JOAQU COUNTY ENVIRONMENTAL HEAD DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY=1DSERVI�C{E REQUEST# <br /> F OWNER 1 OPERATOR"T <br /> Ph ,v , <br /> I/ CN CK if BILLING ADDRIESS❑ <br /> FACILrrY NAME I <br /> SITE ADDRESS <br /> Street Number Direction I I{"-r <br /> t Name C' 7i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> CITY Street Number Street Name <br /> t STATE Zp <br /> PNONE V . Exr. <br /> { } t APN# LAND USE APPLICATION# <br /> PHONE#2 EAT, <br /> { } BOS DISTRICT LOCATION CODE <br /> RE4lrE$TUR CONTRACTOR/ SERVICE REQUESTOR <br /> t <br /> { CHECK if BILLING ADD <br /> BUSINESS NAME 1 PHONE# O EXT. <br /> HOME Or ING DRE5 <br /> MAILFAX# <br /> CITY <br /> 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 speck ENMONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. d. <br /> I also certify that I have prepared this a tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand r , STA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: s '� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG <br /> Efib <br /> If APPLICANT is not the BILLINGPARTY proof of authorization to sign is requ 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: R 11UUYs f r g(Av 0 f" C5.5 <br /> (_ 0 �� �_s et ��`� ,SUN 3 2005 <br /> uu C/ (oss�� <br /> 1p/191 5- ,�l s SAN JOAQUIN COUNTY <br /> f( /.0-,std IGS - ENVIRONMENTAL-4- <br /> � ENVIRONMENTAL <br /> .- <br /> - 'd It a.tis HEALTH DEPARTMENT <br /> ACCEPTED BY: (J L,! EMPLOYEE#: EAT <br /> ASSIGNED T0: � &a EMPLOYEE#:Date Service Competed (if already completed): SERVICE CODE: pjE:S2 42—C- <br /> Fee Amount: _ 00 Amount Paid 37a. (� payment Date 3 J S <br /> Payment Type Invoice# Check# <br /> 1143 Received By: <br /> END 4"2-025 <br /> REVISED 11/1712003 SR FORM(Golden Rod) <br /> t <br />