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SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ^ SERVICE <br /> REQUEST# <br /> OWNER/OPERATOR � _ <br /> ('A C CHECK If BILLING ADDRESS E] <br /> FACILITY NAME C C y Y) 8 e 4- 3 2 Z <br /> $ITE ADDRESS I�4 ° <br /> Street Number I Direction city Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ">Z oe'L IL e <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 <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME } J Y p # L� I Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> I�2� o 0oct. k l/U; c <br /> CITY <br /> �y,�v 1 Jv� <br /> STATE ZIP <br /> BILLING A7CVKNO(,WLEDGEMENT: 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 /> 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 laws. <br /> APPLICANT'S SIGNATURE: /� r DATE: Cl) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER IJ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirie <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: aud 4K V ° yk q <br /> COMMENTS: �1� <br /> e F <br /> tiM.°o�4 <br /> F � <br /> ACCEPTED BY: EMPLOYEE#: DATE: T/1 1.14 <br /> 9F <br /> ASSIGNED TO: 1/J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O(0 P/E: <br /> Fee Amount: I )CJ? Amount Paid )'661 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />