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SAN JOAQUn-4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1� �J c-,*,0-b-7 q �q <br /> OWNER/OPERATOR <br /> dmud 1 �.Z CHECK If BILLING ADDRESS <br /> FACILITY NAME cl Lo <br /> Q <br /> tf <br /> SITE ADDRESS f(�r/ )Pe <br /> r Street Number Direction l Street Name �/ CIty- <br /> --7n Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �(1 l (il <br /> 'Street Number Street Name <br /> CITY STATE ZIP <br /> G'ISaI � <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> V1 A O n-7 CHECK if BILLING ADDRES <br /> BUSINESS NAME ( (— # PHONE# f/_ O EXT. <br /> L-I <br /> HOME or MAILING ADDRESS _ FAX# <br /> 3 ( ) <br /> CITYSTATE �j 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 ork to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, and FEDERAL lav <br /> APPLICANT'SIG--NAT IRE: DATE: <br /> PROPERTY/BUSINESS OWNER+ OP TOR/MANAGER ❑ 0 HER XUTHORIZED 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 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 i�,ip{gYided to me or <br /> my representative. ��y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN J j X016 <br /> �(c- 4 asp H�CNV o N oUNry <br /> OEpgRTM1NT <br /> ACCEPTED BY: >, EMPLOYEE#: DATE: 2- <br /> ASSIGNED TO: �r � EMPLOYEE#: DATE: 5-z-/-/& <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: &0 <br /> Fee Amount: Amount Paid- /3( /. /�/� Payment Date <br /> Payment Type �� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />