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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OIrVP;ER,'OPERATOR <br /> A - CHECK If BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS O` G\rr��` eAc n C <br /> 0 0 Street Number I Di ion 11he Name Cit\/ ` Zin CCodee <br /> NOME Or I ^.IL iNG ADDRESS (if Different from Site Address) /�,_;� <br /> S[reei Number j��I Street Name <br /> CITY K y� ATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (204 - '--A3oto <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) �+ STT rr�i/� `�7/v 7 T c 7 <br /> C. O IlRA.C..�i�lR SERV IC E PEQ'riJESS�OR <br /> REQUESTOR -- <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME` PHONEk EXT. <br /> LA <br /> HOME or MAILING ADDRESS -, L FAX# <br /> I ( ) <br /> CITY r STATE ZIP ?Z2 n <br /> BILLING AChNOWLEDGEIOENT: 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordant with 1 SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> Flt PLiGANTS SIGNAT URE: /� �f �T����� Y, DATE: <br /> PROPERTY/BUSINESS OWNER❑ --VPH.ERATOR i 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 at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provj�or <br /> my representative. �(� //��/ �r9{���Y <br /> Vr <br /> T ?, SERVICE REQUESTED: <br /> COMMENTS: AUG <br /> SAN JOAQUIN COU TY <br /> ENVINOMENTAL <br /> HEALTH DEPARTM <br /> ACCEPTED By, EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed if already completed):U ERVICE CODE: ✓2 � PIE: / <br /> Fee Amount: Amount Paid Payment Dae 6 <br /> _ M _ <br /> Payment Type Invoice# Check# _ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />