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SAN JOAQUIN COUNTY ENVIRONMEIr1`1'AL-MALTI-I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> Sho o Lf o � (3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS EI <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �tion ':� <br /> Street NumberDiJ <br /> Street Name C" Zip Code <br /> F1QME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY <br /> STATE ZIP <br /> PHONE#1 EXT. APN* LAND USE APPLICATION>F <br /> ( I <br /> PHONE#Z Ezr. <br /> I),-,-, )3c,-7_ 1�0 BOS DISTRICT LOCATION CODE <br /> �J CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q 1,- <br /> ` L�, ^'r ur CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME:or MAILING ADDRESS <br /> X DDRESS J FAx# <br /> ` O O 1 I <br /> CITY U A L-7 STATE ZIP 1:1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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,Slandards,§TATIiand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , DATE: 2 ID <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER 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 located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite 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: PAY IVB E['111 <br /> e— <br /> COMMENTS: � � <br /> DEC 2 0 2004 <br /> COUNTY <br /> �TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G EMPLOYEE#: 5� ) DATE: 1 <br /> Date Service Completed (if already Completed): SERVICE CODE: P, <br /> / <br /> Fee Amount: Amount Paid — Payment Date <br /> Payment Type Invoice# Check# Re lved By: <br /> 9 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />