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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH br-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ��. CHECK if BILLING ADDRESS <br /> FACILITY NAME_ — c_ - \ . , <br /> SLTk ADDRESS <br /> I Street Number I Direction ��_ �� tre Na e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> '- c <br /> (:C_.Stee Nu er - Street Name <br /> CITY ST E ZIP <br /> PHONE#1 EXT. APN# 'r LAND USE APPLICATION# <br /> azl <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CpDE <br /> ( ) 0 f <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' \ / CHECK If BILLING ADDRES <br /> BUSINESS NAME (— P, ON C� EXT. <br /> ve CQ <br /> HO Or AILING ADDRESS FAX`#( <br /> v <br /> CITY <br /> J `I T zip',' K <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,STA E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (� �T✓ DATE: <br /> PROPERTY/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 information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERRAMMENT �S 0� <br /> COMMENTS: RECEIVE® <br /> JAN 3 U 2098 flq e <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPT D Y: f7" EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( 1 N EMPLOYEE#: DATE: / <br /> Date Service Completed (if alrea y Completed): SERVICE CODE: OP 1 E: J <br /> Fee Amount: ��— Amount Paid Payment Date ' . 2 .,) , <br /> Payment Type Invoice# Check# Received By: " <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />