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0AIN JUA42UIN C—OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propertji FACILITY ID# SERVICE REQUEST# <br /> 5Ooo q qy <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACIuTY NAME <br /> SITE ADDRESS/�, /' c) 3 7TFL <br /> / � ®G� �� ,1'j Q q 5 Z Z.0 <br /> treet Number DFrection Strytf.(a <br /> ci 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE zip <br /> PHONE#1 34EXT. APN 7►--- _ LAND USE F�gP�IC#TION# <br /> PHON Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME !' '( � 5k B PHONE# EXT' <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <br /> BILLING ACKNn% "GEMENT: 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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 I BUSINESS OWNER D OP BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT f'�7 <br /> IfAPPLICANT 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 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: r� <br /> COMMENTS: <br /> COUNTY <br /> �A`,`,�."���� SAty 7p Pa V4M�ly�A1 <br /> gNA/A tW vt� �I1V1Rfl pAT{1 M�I�1 <br /> ACCEPTED BY: EMPLOYEE#: ATE: b�/J <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 04 Amount Paid ` Payment Date <br /> Payment Type Invoice# Check# r 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />