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SAN JOAQUI. COUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> \ M� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> S U umm <br /> SITE ADD <br /> DRES <br /> Direction 4qeNI am <br /> Zip Code <br /> HO E AILING DDRE S (If Different from Site Address) <br /> Street Number 1 Street Name <br /> CITY ` STATE ZIP <br /> 1 <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (N1) 1 114 -D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I'� �.rlee4 <br /> CHECK If BILLING ADDRESS <br /> BUSINE S N 1 PHONE# EXT. <br /> AM <br /> 1 1 _L4rn n <br /> HOME orJNAILING ADDREPS FAX# <br /> CITY a STAT Et7 /�_ ZIP 052-4 <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 /> I also certify that I have prepared this applica' d that tfTe work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST <br /> APPLICANT'S SIGNATURE: /' DATE: / <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 assessme mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS pro ' . <br /> my representative. A <br /> TYPE OF SERVICE REQUESTED: Fj D <br /> COMMENTS: �� $,t�✓ q 20 <br /> h FNV R QU/N C <br /> ` �� �Q�--� ��Tyo�pgR M cN <br /> FN <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE' PIE: •/ <br /> Fee Amount: Amount Paid .` /,�, ., i , Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />