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SAN JOAQUII RUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J -33 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip 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 /> ( 1 <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �— CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> L s n1-( �L - '� Z <br /> HOME or MAILING ADDRESS FAX# <br /> Z ( ) <br /> CITY -TU Sd A- 9 7 '28 STATE 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 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 RA laws. / <br /> APPLICANT'S SIGNATURE .�: DATE: 1;1.510 1 <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 <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. NT <br /> TYPE OF SERVICE REQUESTED: �j I i s t� ? RECEtUE <br /> COMMENTS: MAY 2 5 2004 <br /> SAN JOAQUIN COUNI`t <br /> ENVIRONMENTAL <br /> HEp,LTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 7 /�L)U DATE:I JA 7 r�Ll <br /> ASSIGNED TO: L-0 ✓/v EMPLOYEE#: ci � DATE: L (• <br /> Date Service Completed (if already completed): SERVICE CODE: (01 P 1 E: <br /> Fee AmoVnt: (� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />