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SAN JOAQL,..4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FArn ITV In it SERVICE REQUEST# <br /> C) W1/ <br /> OWNERR�/ t �00OPERATOR �A1 <br /> �`1 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 2:' <br /> _ �) r <br /> 2:'v Lc�(�1 F G v to i 6- - C'7 S ca e/ J � <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1`) 4( O Cw `'��\'3 \J Street Number Street Name <br /> CITY � �1 I \ w` �, ,( STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (zoo q-0 <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR NAq,4(-�l�l CHECK If BILLING ADDRESS <br /> BUSINESS NAME —.— PHONE# EXT. <br /> 2,C),�� �4---D rub < .=U-1 `l 'O <br /> HOME or MAILING ADDRESS FAX# <br /> XJ Cf,.. Z(29 ( ) <br /> CITYZIP <br /> STATE <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 applic rind)that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA and FE771-- <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER 0116RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑i <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 asses nt information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is Ai me Or <br /> my representative. rq�� <br /> TYPE OF SERVICE REQUESTED: 7 7 � , �® <br /> COMMENTS: <br /> SAN J0 � 201' <br /> —7 q <br /> IC, # 'D5�� /L / y�9 THOQ����T tN?-y <br /> TMSN7 <br /> ACCEPTED BY: EMPLOYEE M DATE: _ <br /> ASSIGNED TO: /r11 j(-A }L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (, PIE: M, <br /> Fee Amount: Amount Paid! Payment Date <br /> Payment Type i Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />