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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATO <br /> C w (� CHECK If BILLING ADDRESS <br /> FACILITY NAME / ' C, <br /> SIDD E <br /> Street Number Dtre'itlon I✓ treet Nark!'/(--i` <br /> HOME Or WILING ADD�ESS (If Different from Site Address) <br /> (v t„ ( , Street Number Street Name <br /> CITY Q � STATE ZIP <br /> �� <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , ' �`J r'/ CHECK if BILLING ADDRES <br /> / <br /> =L2A,,r, <br /> BUSINESS NAME yI c —7 <br /> PHONE# ExT. <br /> HOM ING ADDRESS / FAX# <br /> CITY }Z STATE zip �"2 <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 /> APPLICANT'S SIGNATURE: 4,�yI � ,� DATE: <br /> PROPERTY I BUSINESS OWNER'V 16PERATOR/MANAGER ❑ r THER 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 iLT619%e, <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS Soon as It Is available and at the same time It Is providP. Afmy representative. i'v r <br /> TYPE OF SERVICE REQUESTED: J1 <br /> 1 ® <br /> COMMENTS: <br /> 4 °Ci°q�rM t� <br /> r <br /> ACCEPTED BY: EMPLOYEE M DATE: ._ <br /> ASSIGNED TO: EMPLOYEE M DATE: 15 - <br /> Date <br /> 5-Date Service Completed (if already completed): SERVICE CODE: P I E: o <br /> Fee Amount: Amount Paid ' Payment Date �P s <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />