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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 c,-74— ,s('-� 5 __) (0`r <br /> OWNOPERAT <br /> CHECK if B LLIN ADDR <br /> FACUT111i"ME <br /> SITE ADDRESS �. �� CC',G "'`-�—T��_\ <br /> t ' Street Number Direction treet Name Clt `l Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) rI I z6® -2,�) <br /> PHONE#2 EXT. 1771STRICTDELocan¢N <br /> ( ) l GCj <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S CHECK If BILLING ADDRESS <br /> BUSINESS NAM PHONE# EXT. ' <br /> !E� ��, 5 Com. <br /> HOME OF(1AAILING ARESS c7�y FAX#slo <br /> ) T <br /> v c� <br /> CITY ! C) STA ZE ZIP D <br /> BILLING ACKNOWLEDGEMENT: 1, 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,Stand&rak. STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR ANAGER ❑ 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 environmentaUsite 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: 7 <br /> EAYMFNI <br /> COMMENTS: RECEIVED <br /> JUN 2 4 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ® EMPLOYEE#: C)3. DATE 2 tE D <br /> ASSIGNED TO: cQ-tb uL EMPLOYEE#: Z(0-® DATE: & 2 O <br /> Date Service Completed/(if already completed): SERVICE CODE: IC PIE: <br /> Z3 U b <br /> Fee Amount: t Amount Paid V31,5, 0 Payment Date a-� <br /> D <br /> Payment Type ✓ Invoice# Check# LO Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />