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lglhl <br /> AN JOAQUIISOUNTY ENVIRONMENTAL EALT PART ENT <br /> SERVICE REQUEST <br /> VMS <br /> `Ty ''` u roperty FACILITY ID# SERVICE REQUES # <br /> OWNER OPERATOR <br /> CHECK if BILLING ADDRESS <br /> & <br /> FACILITY NAME <br /> SITE ADDRESS <br /> StreeTNurhber Direction Street Name City 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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 001 <br /> CONTRACTOR/ SERVICE REQUESTOR � <br /> REQUESTOR <br /> <� CHECK If BILLING ADDRE S <br /> 69 <br /> BUSINESS NAME PHONE# Ex <br /> (90.)) -3 4� <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP Q � <br /> �vC✓Li v� <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 or <br /> activity will be billed to me or my business identified on this form. <br /> I also certify that I have prepared this a lic 'stion and that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, S AT and FE AL law, <br /> APPLICANT'S SIGNATURE: '' DATE: <br /> PROPERTY I BUSINESS OWNER❑ PERAT R MANAG ❑ 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 0(- <br /> COMMENTS: T <br /> RECEIVED) <br /> USH SEP 2 4 2013 RUSH <br /> SAN JOAQUIN COUNTY <br /> ENV'IROMENTAL <br /> P <br /> ACCEPTED BY: all r>-, EMPLOYEE#: ?'6 O DATE: 41 J_q ` <br /> ASSIGNED TO: s ® EMPLOYEE#: 1 C� DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: PIE: ?JO <br /> Fee Amount: I Amount Paid ,S�®. Payment Date <br /> Payment Type Invoice# Check# 13 FReceived By:d <br /> l <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />