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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C '� � 1r I �-L t DO 5 0 S K o o <br /> OWNER/OPERATO <br /> D Y I �� 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME j L �S\ <br /> SITE ADDRESS <br /> J r (p <br /> 1 / Street Number Direction Street Name CI ZjD Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STAT V ZIP <br /> � Ocl� C <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C l CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 0✓ I <br /> HOME Or MAILING ADDRESS FAX# <br /> ' v L � ► I Qn G(,�� ( ) <br /> CITY ` Lv _ J/, STATE 1i ZIP <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, STFEDERAL IBWS. <br /> APPLICANT'S SIGNATURE: <br /> Z t� DATE: % G <br /> PROPERTY I BUSINESS OWNER❑ C OPERATOR/I,ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT is not the BILLIN P TY,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: V Md e S "M <br /> COMMENTS: <br /> ( f� o~ Gv n llF�1/ IY YI <br /> ACCEPTED BY: kn p EMPLOYEE#: DATE: �� �O '/n <br /> ASSIGNED TO: { `s(a ( ((h J <br /> EMPLOYEE#: DATE: 2 I <br /> O AF' <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> J 0 <br /> Fee Amount: (;j 9 Amount Paid�G c5?� Payment Date 1 I <br /> Payment Type 8 Y I Invoice# Check# Received By: , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />