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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHIPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Perwnen (owe rim S�0-, Oag► L0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> r <br /> FACILITY NA <br /> SITE ADDRESS <br /> I I Street Number ileCtio <br /> Dn 1'CI 1 t/ tr et Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �/ ,/ y <br /> J� Vl y-\ �1 Street Number Street Name <br /> CITY ` <br /> PHONE#1/v�",v'� $TL 14 <br /> TE ZIP <br /> EXT. APN# LAND USE APPLICATION# <br /> 71 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH NE# EXT. <br /> t� - yS <br /> HOME or MAILING ADDRESS FAX# <br /> 2-02 '2r- ( ) <br /> CITY STATE C ZIP qL � <br /> BILLING ACKNOWLEDGEMENT: <br /> 1, 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: f/ 9l 9 <br /> PROPERTY/BUSINESS OWNEga OPE TOR/MANAGER ❑ 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 pr�> � the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environm ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and RECENED is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> C "� Ita tion <br /> COMMENTS: SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � EMPLOYEE#: $ �' DATE: 1M 1 <br /> ASSIGNED TO: R M 6 I(�H V n EMPLOYEE#: '39 - DATE: 91q /11 <br /> Date Service Completed (If already completed): SERVICE CODE: 06 1 i E: 103 <br /> Fee Amount: UE= Amount Paid l S2 Payment Date <br /> Payment TypeL Invoice# Check-b �js �� Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />