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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ���'C <br /> C" v FArn ITV m# SFRVICE REQUEST# <br /> rt tdQ f4�% -7�1 �� W 7k yO-7 <br /> OWNER/OPERATOR P no IV A-P'`f(/1f •d ri—r-a v V" �. <br /> - T1 CHECK If BILLING ADDRESS <br /> FACILITY NAME r-46VV1 Gn. ' ° l <br /> SITE ADDRESS Q <br /> Sue-h umber Direcion I Street Name city Zip Code <br /> t HOME or MAILINGPDRTSS (If Different from Site Address) 1 <br /> Cid S 4 : L ' Street Number Street Name <br /> CITY/ � STATE ZIP <br /> ✓{-Q c r� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> .�., , �p^"`- CHECK If BILLING ADDRESS <br /> BUSINESS NAME -r— i C PHONE# EXT. <br /> Telei <br /> C-) <br /> lZ <br /> HOME or MAILING ADDRESS_ FAX# <br /> CITY Jr STATE/ ZIP Q C <br /> S C+ ` / 7 <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 /> 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 /> AP'PLICANT'S SIGNAT RE: r�� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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: FI✓xd <br /> COMMENTS: RECE»' Y <br /> C`-)C(►icl e- 0 -(-' o "�n e(— NOV t 1 <br /> L D 7l,OX <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ffflffi <br /> ACCEPTED BY: , - EMPLOYEE#: <br /> ASSIGNED TO: ` 1 EMPLOYEE#: DATE: c _ <br /> Date Service Completed (If already completed): SERVICE CODE: n P/E: <br /> Fee Amount: 1C— Amount Paid ( S� Payment Date a <br /> Payment Type << Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />