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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 4pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s r������ <br /> OWNER/OPE TOR <br /> 4\A, CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> SIT F�ApQjE Street Number <br /> DIrecVQn `� ` �1 tree[No v` I ZIL)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# l LAND USE APPLICATION# <br /> (Z' ) 9ZS- -2Z(.9O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ ` <br /> CHECK if BILLING ADDRESS CI <br /> BUSINESS NAME L� PHONE# ExT, <br /> S <br /> m S"' o <br /> HOME or MAILING ADDRESS FAX# I� <br /> 32 06�� 11,13 (5S.�)4(1't- <br /> CITY l n iD STATE er+ ZIP <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 <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 applicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar A nd FEDERAL 12wS.APPLICANT'S SIGNATURE: DATE: 2L/f/4� <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEI Gtr <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 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. A <br /> TYPE OF SERVICE REQUESTED: > ) (h FC�c FNT <br /> COMMENTS: CIO <br /> 7)�aN�AF 4LMY <br /> ACCEPTED BY: C�p�� EMPLOYEE M DATE: <br /> ASSIGNED TO: -� EMPLOYEE M DATE: _I <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 <br /> Fee Amount: 0 L) Amount Pal 17 DD Payment Date �L <br /> Payment Type ✓ Invoice# Check# �,Z�7 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />