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SAN JOAQUL —OUNTY ENVIRONMENTAL HEALTH _ —PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0025 2c)Z on12 � <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME I vI COS y �(/I►c�I J CL's LAS l7C �'l`'� ,� <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) GCA(2— <br /> t Street Number J w a&r <br /> Street Name <br /> CITY STATE Cn ZIP ��•�1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> V11) L- -,A Z13 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C �fJ hl STATE C 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 SIGNATURE: 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, 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: �KW vVG V L► 1/'c�- ` <br /> COMMENTS: <br /> ACCEPTED BY: 6W J EMPLOYEE#: DATE: <br /> ASSIGNED TO: Cy\V �C 0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: 17 <br /> Fee Amount: Amount Paid fi`r :j .= PaymeLntt Dater <br /> Payment Type ; Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />