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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �i <br /> co-73 <br /> OWNER/OPERATOR <br /> (.HECK If BILLING ADDRESS <br /> -- <br /> FACILITY NAME �7 <br /> SITE ADDRESS c-g-I�n <br /> lk <br /> '71-7o. � � v a Number Direction CVCStreet Name ��I Cid .__ Zip Code <br /> HOME Or IN"AILING AD')RESS (If Different 1 orn Site Address) <br /> Street Number ,j'reet Name__— <br /> CITY STATE ZIF <br /> PHONE#1 Ext A?p!# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION(ADE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK IfBILLING ADDRESS El <br /> BUSINESS NAME / P/HONE# EXT. <br /> K I0 7/ <br /> HOME or MAILIN-,✓^•,)DRESS] FAX# <br /> CITY � STATE/7 ZIF����� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or bu:;iness owner, operator or auttiorized 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 /> also certify that i `ia : prepared this application and that the work to be performed wil' be done in accordance witn all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, TA an (FE ERAL laws. <br /> APPLICANT'S SIGNATURE: � <br /> --� DATE: C <br /> PROPERTY BUSINESS OWNE R' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfATYP–L—IcANIS not the BILLING PARTY,proof of authorization to sign is required Tirl <br /> AUTHORIZATION TO RELEASE INFORMATION: When applica�le, I, the owner or operator of the property located at the abo�a <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS rrovlded tine Or <br /> my representative. ; <br /> TYPE OF SERVICE REQUESTED: Q� w• i , - <br /> COMMENTS: iN J0 0 �P <br /> • <br /> H FNAq�i '' <br /> T <br /> NT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: I, O 1� <br /> ASSIGNED TO: EMPLOYEE#; DATE: I I <br /> Dare Service i Dmpieted (if already completed): SERVICE CC DE' PIE: <br /> Fee Amount: �' .(, Amount Paid Payment Dntc <br /> Payment Type Invoice# �— Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />