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SAN JOAQL 2OUNTY ENVIRONMENTAL HEALT_ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR f✓ <br /> `u I CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> C 1� <br /> SITE ADDRESS Lr1 b 1 <br /> T. �t� ,�iZ�;� <br /> JAM <br /> Street Number Direction Street ame Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number _.) Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> [PHONE#2 EXT• BOS DISTRICT -7LOCATION CODE <br /> l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR `'w CHECK If BILLING ADDRESS Tr <br /> �vin/1C15 lc'� <br /> BUSINESS NAME PHONE# Iq EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> �WWvi - <br /> CITY !-h <br /> (J I STATE ! ;.1 zip <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I 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. <br /> APPLICANT'S SIGNATLJRE: 3cc T , ,�,`��, DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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, I, the owner or operator of the priwerty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environ SSS ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available att it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C O z <br /> COMMENTS: JOAQU1 <br /> NT <br /> ACCEPTED BY: V Vv Y/V LL] EMPLOYEE#: DATE: Is '3 1R <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 00 I P I E: X003 <br /> Fee Amount: *(5 Z Amount Paid (,ra Payment Date 1 <br /> Payment Type r� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />