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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WNER/OP BATOR <br /> < -- `1 CHECK If BILLING ADDRESS <br /> ACIUTY NAME t�/I�YX(j'\"r v` CJ <br /> SITE ADDRESS V1CT(�rn l V t SCI C' <br /> CP S�reet Number Direction �^ Street Name Ci Z de <br /> H ME Or MAILI G ADD ESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY I c STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> P <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> l � cu e <br /> BINESS N E CHECK If BILLING ADDRESS <br /> y PHONE# EXT. <br /> C 1 �� z 7 <br /> HOME Or MAILIN A,DDRR$S, FAX# <br /> C C\ ( ) <br /> C STATE ZIP Oa <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 EN RONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> activity will be billed to me or my business as identifie on this form. <br /> also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE FEDE AL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1 17--- 2-3 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑' r <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is pro { _t0 me or <br /> my representative. - Y <br /> TYPE OF SERVICE REQUESTED: WL4 CA e_ Sg!.L C--+f sl ti n � 1��w COMN'LNTS: S 23V, 0WIVq�T �q/ <br /> FN <br /> ACCEPTED BY: EMPLOYEE#: DATE: (712,-141(5 <br /> ASSIGNED TO: �1�7M ISL '�/^ � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 1 SERVICE CODE: ( I P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />