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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 10 P ERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Cha �v c �r <br /> SITEADDRESS (�3s1 Co ,0. D� . S�ck�ol^ gSz Oq <br /> Street Number I Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c ) 0'75 3,�a I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> c ) C - D t - Cos <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> t ) <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 11 <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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: �j � <br /> QC. Ce_ S<< � �1C2Vh <br /> COMMENTS: rCTV%(ekex, <br /> t`c h+c,_ �-G\ �cvcLtig S)?- �cac . Vw.e- vv\.. <br /> ACCEPTED BY: EMPLOYEE M C tC C'-0 DATE: •1 i f�� 3 <br /> ASSIGNED TO: EMPLOYEEM C?CK37 DATE:,qs hZ <br /> Date Service Completed (if already completed): (47/` SERVICE CODE: /)� ' PIE: �iii <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 />