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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S, VICE REQUEST# <br /> OWNER/OPERATOR usin <br /> s �� <br /> r V �(/a1 CHECK If BILLING ADDRESS <br /> FACILITY NAME ` (! � ' ok�� <br /> SITE ADDRESS 1v� (//�J/J� V <br /> Street Number Direction lfkor�)bs'r'et Name S- "C� 40/? Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Sit Address) <br /> �O Street Number Street Name <br /> CITY ` STATE ZIPrA4 <br /> PHONE#16z;�? EXT. APN# LAND USE APPLICATION# <br /> Q <br /> PHONE#2 EXT• 1166�� <br /> STRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( _-o lurcikari CHECK if BILLING ADDRES <br /> BUSINESS NAME � �1/ �2 PHONE# EXT. <br /> jn - 36t'v <br /> HOME or MAILING ADDRESS (AX# ) <br /> i <br /> CITY STATE ZIP / An <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I 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, 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 provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C/� <br /> COMMENTS: e <br /> AMY ? y 2p19 <br /> Sqj�IgQIj CO <br /> HEALT NTA <br /> to) N <br /> ACCEPTED BY: / / EMPLOYEE#: S DATE: <br /> ASSIGNED TO: c/l EMPLOYEE#: U DATE: ✓ <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: 16V3 <br /> 621 <br /> Fee Amount: 5 -00 Amount Paid S r Payment Date 5 12_z4 11q <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />