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SAN .JOAQutrl COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> k; <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WNER/ ERATO I ��� <br /> 1 <br /> UAN <br /> CHECK if BILLING ADDRESS <br /> ACIUTY NAME <br /> SITE DDR S F717.,—Ode <br /> Street Number Direction `' Street Name -Tyup i <br /> HOME nr_MAILING ADDRESS (If Different from Site Address) <br /> r�� •�' Y Ls� Street Number Street Name <br /> CITYNl STATE ZI 1�3 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHON #2 EXT. BOS DISTRICT LOCATION CODE <br /> ('204) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME EvoPHONE# 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 /> 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 prq FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �-- <br /> �cM� ''' ti �"'L DATE:(y..2 �"! 'ZDt S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OT9R AUTHORIZED AGENT ❑ <br /> /f 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 provi d to me Or <br /> my representative. �r1A <br /> TYPE OF SERVICE REQUESTED: ©� �� �� /O'er r%r. 7* <br /> COMMENTS: D <br /> SAroJoe1.92p/ <br /> NE EN pU�M COU <br /> ALTh��qE TME TJ, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: l/ <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 30 Amount P i 3 01 OD Payment at :L// 5-- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />