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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME UA-1 <br /> SITE ADDRESS Ov <br /> 7L 7 1� D o , q�Z 1 5 <br /> 1,Street Number Direction Street Name Ci i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) c: <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <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 <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,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 same time it is <br /> provided to Ire or my representative. <br /> TYPE OF SERVICE REQUESTED: WG0; <br /> COMMENTS: ;V- <br /> Fr <br /> ACCEPTED BY: U- 1 EMPLOYEE#: O DATE: /Z71) <br /> Q <br /> ASSIGNED TO: CA k EMPLOYEE M. o DATE: <br /> Date Service Completed (if already completed): Z 7��S SERVICE CODE: dd PIE: `7 71,,O <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />