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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N( k- t?+-- ) -n 9-7 13(x--%,-7 a,,,)-q <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME I ( VV 4 �,I\�1,�, <br /> SITE ADDRESS t�'�- l, r \" <br /> L` �cC (V� <br /> Street Number Direction Street N e Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> v eA 111—�, S � L— <br /> BUSINESS NAME / —�� PHONE# E� <br /> A4—A-- l 12- <br /> HOME or MAILING ADDRESS FAX# <br /> CITY J � � $TATE ZIP C S zJ' <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 project Or <br /> 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,STATE an DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I(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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessor t information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS prC (( it]tZQr <br /> my representative. T <br /> 1W CZ,I VED <br /> TYPE OF SERVICE REQUESTED: V`tel �(�(I VI—L i2 n <br /> COMMENTS: U <br /> SA <br /> EJ0R UINCSU <br /> HEAL7-H,DE ARrAE r1' <br /> r <br /> ACCEPTED BY: S EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 06 (- P/E: <br /> Fee Amount: 1 Amount Paid' I c rJ UV Payment Date fs <br /> Payment Type Invoice# Check# Recehled By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />