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SAN JOAQuiN COUNTY ENVIRONMENTAL HEA <br /> LTH IUEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST At <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME <br /> Fcr i DT �Vc ' �l <br /> SITE ADDRESS /i/tcl Y7 'St'reet <br /> f S f U C O✓► JT �f C U 7 <br /> Street Number Direction Street Name city n Zi Code 7 <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 J EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R UESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C+0Crs. 7�67/? 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 and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: Pr ��c' l/7 4 r lj<� 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, 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 assess ormation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is � <br /> my representative. Cel In <br /> TYPE OF SERVICE REQUESTED: (U Ju7 <br /> AI <br /> V <br /> COMMENTS: v h y l/ -� GA)J -VIT SAN J04QUI <br /> H y l�O pgRNTgL <br /> MSN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid ��. Payment Date G <br /> Payment Type Invoice# Ch k#/ . �f '57A Receiv d B <br /> Exp y ma, I Cc," <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />