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SAN JOAQUOUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> R, SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0poas�-0 Y-/ <br /> OWNER/OPERATOR <br /> � CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 4"yI.Y�L/1f <br /> t Street Number Direction S t o C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION III <br /> ( ► Q _cF -o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MmumG3PIDRESS FAX# <br /> (` ► �''' <br /> CITY STATE LP <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 IaWS. <br /> APPLICANT'S SIGNATURE: `� DATE: 1zle /FZ 2 <br /> PROPERTY/BUSINESS OWNER❑ Z OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTf� z�'d (aN//t,f x <br /> IfAPPLICANT 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 me or my representative. I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> /�, A-.-, <br /> 1Z ���..- Z��S_O SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 119 <br /> ASSIGNED TO: EMPLOYEE#: "2 1r2 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: , P/E: ��Q <br /> Fee Amount: Amount Paid Payment Date \1 2-1 0 S <br /> Payment Type Invoice# Check# O 3 S Received By: vV�s <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />