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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T e of Busi ss or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> r r {'� A ��T't( --�-• ��q�t CHECK if BILLING ADDRESS <br /> FA ILITYNA <br /> _ •fin_ \,-� <br /> SITE A DRESS 'i•� � /} ,� ` ,� LL� <br /> Street Number Direction -7 t Ne �' i V Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#11 EXT. APN <br /> ( ) # LA USE APPLICATION <br /> / �� � ' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> ` REQUESTOR f'l� ���•�,,.p <br /> CHECK if BILLING ADDRESS <br /> PHONE# Ext. <br /> � BUSINESS NAME� � .�( �CI VI^ <br /> HOME or MAILING DDRE S FAX# <br /> CITY ` ��; STATE CA ZIP I <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 entified on this form. <br /> I also certify that I have prepared this ap ica on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 3'26 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT` <br /> IfAPPLICANT IS of the BILLING PARTY,proof of authorization to sign is required Time <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: N?' <br /> COMMENTS: I D <br /> MqR 2 9 219 <br /> 10 QU1N CO <br /> pFpMENT N7Y <br /> ACCEPTED BY: 6W EMPLOYEE#: DATE: NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pa• �Q � Payment D to Z9 <br /> Payment Type Invoice# Check# 35 Rece' ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />