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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 i <br /> 6p i C CHECK If BILLING ADDRESS <br /> FACILITY NAME - J <br /> SITE ADDRESS 2�,A�,-A(D r C� � �c�.� ������ 9 cSZ o <br /> Street Number Direction Street Name �J city Zip Code <br /> HOME or MAILING ADD(2�S$Af DIfferRnt from Site Address) <br /> `r / �" ' Sheet Number Street Name <br /> CITY / 7 STATE ZIP <br /> G <br /> x 7 ,! / � / _J U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 5/0 SqS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /�/,^/ /® <br /> �j'/f CHECK If BILLING ADORES <br /> BUSINESS N �� L v � ��,��p- PHONE# 2- 2 EXT. <br /> HOME or MAI LIN DR S V FAX# <br /> . 4 ) <br /> CITY STATE 6- ZIP S L C- <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. 7 <br /> APPLICANT'S SIGNATURE: DATE: / Z` L`- /I(, <br /> PROPERTY I 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 Julormation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same ti 10to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: / <br /> Q i J �Ut NOAr7 <br /> SAN JO' T <br /> TNpE <br /> Du n N EPARSMENT <br /> ACCEPTED BY: l 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: " EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'll \ PIE: lid <br /> Fee Amount: I �' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: ` <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />