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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'S <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILnY NAME <br /> SITE ADDRESS C`12') --� t y� Y Y p0.�� S�C-� �^ (:\s a <br /> og <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) L-V36''1 E,���-��� C� <br /> Street Number ` Street Name <br /> CITY ,1 STATE C-Al\ ZIP C � <br /> PHONE#1 APN# <br /> LAND USE APPLICATION# <br /> E'tT• <br /> (SIS) lS`t $Soo Gam- lZ -uS <br /> PHONE#2 �• BOS DISTRICT LOCATION CODE <br /> ( ) I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ CHECK if BILLING ADDRESS <br /> \ b PHONE# �• <br /> BUSINESS NAME \\ ,Y� `6 ?J- "1 a- <br /> HOME or MAILING ADDRE \-gyp FAx# <br /> C:) �a� <br /> CITY ` STATE n tp 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,StandardsTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 29 <br /> If APPLICANT is not theBILLINGPARTY,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. uS t�LC�� f' 1 <br /> ' PAY( <br /> TYPE OF SERVICE REQUESTED: G k� �S ` L- ENT <br /> `C 2V�tJ <br /> COMMENTS: <br /> JUN 3 0 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 0 L l A EMPLOYEE#: DATE: & -SC' oe <br /> ASSIGNED TO: �- (/'_L(f EMPLOYEE#: `l"�t7 DATE: (03 U rJ <br /> Date Service Completed (if already completed): SERVICE CODE: Cr,� PIE: �3 C) <br /> Amount Paid b Payment Date ? <br /> Fee Amount:. . � �t 't;.L,, <br /> Payment Type Invoice# Check# 4 Z O Received By: <br /> SR FORM(Golden Rod)' <br /> EHO 48-02-025 <br /> REVISED 11/17/2003 <br />