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R L � <br /> Q <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR t <br /> 15;A"6v Iris rn CHECK if BILLING ADDRESS❑ � <br /> FACILITY NAME <br /> SITE ADDRESS <br />( Street Number Direction Street Name cityZI Code <br /> FfOME Or MAILING ADDRESS (if Different from Site Address) <br /> -Z-78<> �I x <br /> Street Number Street Name "" § <br /> CITY STATE ZIP <br /> PHONE#t EXT APN LAND USE APPLICATION# r <br /> 13o-o3l <br /> a PHONE#2 EXT. BOS DISTRICT LOCATION CODEe. <br /> 4 <br /> dY <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU£STOR <br /> Ml sf-6 Tvy CHECK 11 BILLING ADDRESS A <br /> BUSINESS NAME 01i- s, . / � PHDNE# <br /> EXT <br /> HOME or MAILING ADDRESSP FAX# / ti <br /> CITY Cr6i� + STATE ZIP <br /> ` : a <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 protect <br /> or activity will be billed to me or my business as identified on this form. r <br /> I also certifythat I have prepared this application and that the work to be performed will be done in accordance with all SAN JOA <br /> P P PP P QUIIV r <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> p <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> ��. _._._...__..._. 's <br /> PROPERTY I BUSINESS OWNER© OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BILLING PARTY Proof of authorization to sigh 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 env ironmental/site assessment {r <br /> information to the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an a It IS ry <br /> provided to me or my representative. GFIVE <br /> RE <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: lZ�3NOV § <br /> r h-A 7 <br /> SAN JOAQUIN COUNT-YY: <br /> ENViRONMENTA! % <br /> HEALTH DEPARTMENT <br /> Y. <br /> A g <br /> ACCEPTED BY: EMPLOYEE#: )Qfi' DATE: <br /> ASSIGNED TO: EMPLOYEE#: �SGJ DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: �� P i E: <br /> Fee Amount: ,�° AmountPaid 0-0Payment Date <br /> Payment Type invoice# Check# Received By: lug <br /> EHD 46-02-025 v ! " SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />