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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bb 71 a � <br /> OWNER I OPERATOR <br /> / 1ko CHECK If BILLING ADDRES <br /> FACILITY NAME Oyk - l <br /> SITE ADDRESS -Z q t7J <br /> Street Number Direction Street Name City Zia Code <br /> HOME or MAILING AD RESS (If Different from Site Address) <br /> Street Number7 Street Name <br /> CITY STAT ZIP <br /> PHONE#1 EXT nq- <br /> APN# LAND USE APPLICATION# <br /> 4 3I oC)z <br /> / PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> J 02( ) —'11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 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 and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: ?n-c-, Q- / U DATE: d(.0 <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 property located atbove <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmentai/site assessmenjt�.J A, <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provl09 �1Zt�/� <br /> my representative. �® <br /> TYPE OF SERVICE REQUESTED: �l L� /L, SqN 6 Z 1$ <br /> COMMENTS: &014C CO <br /> CV VA- M NT <br /> ACCEPTED B C, i �� EMPLOYEE#: DATE: <br /> i 5 <br /> ASSIGNED TO: .I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: J Amount Paid 3 b Payment Date �S <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />