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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> )l fVV1 n itiL G a <br /> FACILITY NAME i <br /> CSLITEADDRESS 33�toz- C !J <br /> 53'700, 3�I0Street Number Direction Street Name Ci Zi Code' <br /> HOME or MAILING ADDRESS (if Different from Site Address) t I/ r <br /> 55-7 Zp Street Number J Street Name <br /> CA <br /> CITY T— <br /> STATE ZIP <br /> PHONE#1 EXT. APN# LANDy PLICATION# <br /> (Zoq l 835 - Z71 7-7 4 3 <br /> PHONE#2 EXT. BOP'DISTRICT LOCATIO ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> N REQUESTO CHECK if BILLING ADDRESS <br /> aun ft.- <br /> BUSINESS NAME b1'� �; U PHONE# EXT <br /> HomE or MAIUNG ADDRESS FAX# <br /> •o X30 <br /> STATE /t M ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, o`-pfetrator 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 me 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,ST and F E L <br /> APPLICANT'S SIGNATURE: DATES: <br /> PROPERTY I BUSINESS OWNER❑ PERATOR I MANA ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARS proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 11,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 environmentaVsite'assessment <br /> information to the SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time l .it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AAW I�AYME`NT , <br /> EI•VED <br /> r l e C JAN 2 5 2011 <br /> SAN JOAQUI14 coUNTY <br /> ACCEPTED BY' EMPLOYEE#: <br /> ASSIGNED T 7�f EMPLOYEE#: �O rj�j� DATE: <br /> I Date Service Completed (if already comple ed): SERVICE GODS:`✓�"� PIE: ' <br /> Fee Amount: QO Amount Paid aOC) Payment Date <br /> Payment Type Invoice# Check# Received <� <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> r� <br />