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SAN JOAQU1ty 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 /> � Lt o c �YcY G <br /> FACILITY NAM <br /> E/j /4 <br /> SITE AWRES stre5 �� k <br /> i�etNumber Direction tr et ame / Code <br /> Ho M r /I'7IN'G DD/RE,SS�(If Differ(e/1��t from Site Add r ss) <br /> tD Vv l.� — Street Number Street Name <br /> CITY � STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ZSR 2 /1 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORA O <br /> � '� <br /> ��� JI �t CHECK If BILLING ADDRESS <br /> 15 BUSINESS NAME /� / Jq /;— PI NE# /1///' EXT. <br /> HOME or MAILING ADDRES f� �� �• L FAX# ) <br /> CITY ^ STATE /) ZIP � 2-/(J' <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 /> 1 also certify that I have prepared this application and that the wor O be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL law . ` J <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER UTHORIZED AGENT ❑ <br /> If APPLICANT is no, 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 assess.r(�]ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the sameGO �ft1��I itvided to me or <br /> my representative. <br /> —Ilan <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: D 10 <br /> SE C'&o <br /> 30Aa��µFN'Cr'�'�� <br /> ACCEPTED BY: fY(� u �� EMPLOYEE#: DATE: <br /> ASSIGNED TO: ., EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: CJu 1 PIE: <br /> Fee Amount: '10? Amount Paid s2 � Payment Date /p ' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />