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SAN JOAQI COUNTY ENVIRONMENTAL HEAL', DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fL)CO Tf 6 qoqoiq,; <br /> OWNER/OPERATOR <br /> Lk i 0 U-LY CA_ CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��\ <br /> U(� u I Street Number Street Name <br /> CITY STATE ZIP <br /> SSD a� � a C1 S'2- i Ci-) <br /> PHONE#1 ExT- APN# LAND USE APPLICATION# <br /> ckfj L 1 \1 GZ <br /> P( t)HONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 4�G - -5V <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> �Ko l <br /> PHONE# Ex-r. <br /> BUSINESS NAME (2-01) <br /> -7�/ <br /> HOME or MAILING ADDRESS / FAX# <br /> CITY STATE C ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL. laws. q <br /> APPLICANT'S SIGNATURE: (` � _J� DATE:: <br /> PROPERTY/BUSINESS OWN 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, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T 1 t-1 �,)1 etu v`( �J T tL A Lr ,� 'AY <br /> COMMENTS: Cel a� <br /> FES 08 <br /> 1� <br /> `SAN JOA <br /> N COON <br /> 114TH p N�ENT/,L Y <br /> ACCEPTED BY: EMPLOYEE#: QC) DATE: N <br /> -n LArn <br /> ASSIGNED TO: EMPLOYEE#: C1) DATE: I C <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Pa UV Payment Date r2 / <br /> Payment Type Invoice# Ch # �. Rec ived By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />