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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Odl�Y67 5"0 -110q ` <br /> OWNER/OPERATOR <br /> yn�`( C/ •�./�� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Z fo 12 C f <br /> rV / <br /> SITE ADDRESS /�� <br /> G 7 v l Street Number Direction Street Name city it)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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR % n / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# EXT. <br /> HOME or MAILING ADDRESS 2 4 4 FAX# <br /> CITY �C / STATE L 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 and FEDERAL I@WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> y/ /�' z°a'S(T—9 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 /> t0 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: I-Z7,Ud �G�Y�C �2�/�1 PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 032014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH IDEPARTMEW <br /> ACCEPTED BY: 11 /I EMPLOYEE#: DATE: r Z 14 <br /> ASSIGNED TO: V� EMPLOYEE#: DATE: <br /> Date Service Completed (if already comple ): SERVICE CODE: D C P 1 E: /60 -S <br /> Fee Amount: Amount Paid I '" Payment Date <br /> Payment Type ,2 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />