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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVIC QUEST# <br /> oW <br /> OWNE <br /> v j�O� CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDR SS •r� 1 �r�' r � <br /> Street Number Direction J1 C Street Narr, l t Y� �} Ci Zi CodelJ <br /> HOME Or MAILING ADD SS (If Different from Site Address) <br /> �L Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ZG� <br /> 4031— 5'7 2 <br /> PHONE f/2 EXT. [BoOs-61STRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR iauj <br /> 6c�l C CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME C PHONE# r EXT. <br /> l2-0 <br /> HOME or MAILING ADD SS l _'� FAX# <br /> CITY � STATE J ZIP 3021 <br /> BILLING ACKNO LEDGEMENT: 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 applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE FE AL�IZ4 APPLICANT'S SIGNATURE: DATE: <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: t o"T aQ M� <br /> �r <br /> COMMENTS: MAY <br /> Is"INj <br /> F/yV�gQU/ <br /> HT 0 'y NT,q�r' <br /> ACCEPTED BY: EMPLOYEE#: ` DATE: $� / TMFNP <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r?j (/E: <br /> Fee Amount: Amount Pai Cl 10 f" p� Payment Date S / <br /> Payment Type Invoice# Check# fit' D G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> -Q <br />