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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0C:�2 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME LA) �T:I L l V l M f('t�-LN'� <br /> SITE ADDRESS t5 of �� G�mlt A) �CT�I 9G,1'4 <br /> Street Number Direction I Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 9N <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �C0��A l y� ��p a <br /> I► ' I J X) CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS ` +� /�i t ,t u J� FAX# <br /> CITY < I L� Lr I STATE��1/ ZIP 01X <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,STATE andel EIjAL as s. <br /> APPLICANT'S SIGNATURE: ✓ 1 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN ❑ OTHER AUTHORIZED AGENT ❑ <br /> It 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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> JUL 0 8 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH CDCF'ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ��1 PIE: t(vow <br /> Fee Amount: -412,0-c D( 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 />