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SAN JOAQUIUNTY ENVIRONMENTAL HEALTOYEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> . k-oLk,, <br /> OWNER/ PERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> a- 3 <br /> SITE ADDRESS ^G ��� `, _ f` �Z /9 <br /> Street umber Direction Street Nam Ci Zi Code l <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ETT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ETT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR P <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME / t PHONE# EM' <br /> &11' f ( <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMEN . 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/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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: YM�N <br /> COMMENTS: ` <br /> V PR,�B <br /> M IGoUNn <br /> SPN 30 P NM FTMENT <br /> NEA SN UEpP <br /> ACCEPTED BY: EMPLOYEE#: S- DATE: <br /> ASSIGNED TO: EMPLOYEE#: S- DATE: `S . <br /> Date Service Completed (if already completed): SERVICE CODE: r PIE: u <br /> Fee Amount: �-� Amount Paid 2'1CA Payment Date 3 �� <br /> Payment Type Invoice# Check# Received By: �( <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />