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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ''^ `_ S�_ / CHECK If BILLING ADDRESS <br /> FACILITY NAME �,C ry v1 D tb yq u� <br /> SITE ADDRESS <br /> Street Number I Direction Ystreet Name CIt C de <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 00 Street Number Street Name <br /> CITY STATE <br /> r'vO©f'572) 0144-- <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 0Z) C5 <br /> PHONE#2 Err. BOS DISTRIC LOCATfON ODE <br /> 3 ,Y s— c S k_)LI <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> SIy �� wS ' <br /> �. 3�yyC <br /> HOME Or MAILING ADDRESS /� �� � FAX# ) <br /> �p ✓ ��/yy4i <br /> CITY ^ STATE ZIP 9J,3 f(_ <br /> BILLING ACKNOWLED-iG—EMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAJ,laws. / <br /> APPLICANT'S SIGNATURE: ��/(� LL DATE: ` <br /> PROPERTY I BUSINESS OWNERZI� OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT❑ E/�-► <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> TYPE OF SERVICE REQUESTED: �j � 4 V <br /> COMMENTS: <br /> 13AN joAQU <br /> ACCEPTED BY: l � � , l EMPLOYEE#: U JM pMF <br /> ASSIGNED TO: Ln , V EMPLOYEE#: DATE: 1 r <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: (I/1O L <br /> Fee Amount: IC�7 p� Amount Paid (�2: Payment Date I lY <br /> Payment Type Invoice# ## ($ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 lJ 5 <br />