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SAN JOAQU) OUNTY ENVIRONMENTAL HEAL T PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> an <br /> it / <br /> x OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SITEADDRESS��/ � F , ,1� �� `� 1 <br /> Street Number Direction {�'-j StreetName (� Cit Zi Co,Gd)e Z <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY- STATE ZIP <br /> PHONE 91 EXT APN# LAND USE APPLICATION#. ow <br /> PHONE#TExr. BOS DISTRICT LOCATION CODE <br /> ( <br /> - CONTRACTOR f SERVICE REQUESTOR <br /> 'RWUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHO E _ EXT. <br /> HOME or MAILING ADDRESS FAX <br /> X53MINE) ( 634 <br /> - <br /> CITY STATE ZIP <br /> IIIZLING-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: Til7, <br /> PROPERTY/BUSINESS O WNER EI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT.is not theBZmNGPARTY proof of authorization to sign is required <br /> Title <br /> T �— — -— ---- -- - — -- <br /> AIITFiORIZATION TO RELEASE INT©RMATION: 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 environmentaUsite assessment <br /> InOrmatlon to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAT TH 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: ' <br /> COMMENT$ <br /> r _ _ RECEIVED <br /> Ri <br /> JUL -5 2012 <br /> USK7� OUIN.COUNTY <br /> SAN JOA NMENTAL <br /> - H&TM DEPARTMENT <br /> x ; ACCEPTED BY: EMPLOYEE#: DATE: <br /> $IGNEQ TO: -EMPLOYEE#: DATE: <br /> Date <br /> Service Completed (if already comple d): SERVICE CODE: P/E:1/ <br /> Fee Amount Y Amount Paid Payment Date <br /> Pa en T e. Invoice# Check# �3 <br /> Yr►I YP Received By: <br /> I <br />