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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �V N V G CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> �q0 WS <br /> SITE ADDRESS d 2jq(, I <br /> Street Number DirectioGp-cWjon `'-' � <br /> HOME Or MAILING ADDRESS (If Different from Site Address) tree Name cit <br /> Zi Codee <br /> U n <br /> CITY 9. Street Number <br /> � Street Name <br /> 5T O cj:�rtb V., STATE ZIP <br /> PHONE#1 EXT. 95-2- e, <br /> eAPN# LAND USE APPLICATION# <br /> PHONE 92 EXT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> REQUESTOR CONTRACTOR / SERVICE REQUESTOR <br /> u S-n N� Seo oI, CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME <br /> Cc.,r kf-�o 2---F— LN _l L �) PHQNE# Exr. <br /> rT <br /> HOME or MAILING ADDRESS FAx# <br /> CITY C OC STATE ZIP <br /> "BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator p 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,STt <br /> and FED RAL laws. 1 <br /> APPLICANT'S SIGNATURE: L A� DATE: ` `L`fj Z C.) <br /> PROPERTY/BUSINESS OWNERR, O /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 <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 sar>�jilne it is <br /> provided to me or my representative. ff'"'IyYA� <br /> TYPE OF SERVICE REQUESTED: 0 0 ((� C �, rvftcel <br /> COMMENTS: (� JAN <br /> 1 $ <br /> s�JORHEAIV/OIV/N COL <br /> N7y&q rNF� TQ <br /> Mk <br /> ACCEPTED BY: ..f -es C c, EMPLOYEE#: DATE: Z4_ <br /> ASSIGNED TO: 1 r EMPLOYEE#: DATE: , (O <br /> Date Service Completed (if already completed): SERVICE CODE: �2 PIE. r <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHIDREV SED 11/5 ` }� ) ^ /_ (� SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> r <br />