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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CCHECK If BILLING ADDRESS E] <br /> FACILITY NAME I S <br /> SITE ADDRESS t /� <br /> � <br /> Street Number Direction Street ame TCit v '11414('11 Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Addres ) <br /> rS (''1 Street Number Street Name <br /> CITY l I STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE 92 /- EXT. BOS DISTRICTLOCATION CODE <br /> �� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' O CHECK If BILLING ADDRESS <br /> c <br /> i BUSINESS NAME II PHONE# EXT. <br /> Cl t C'td nct cz/ <br /> HOME or MAILING ADDRESS FAX# ��- <br /> uS ( ) <br /> CITY t- � _ STATE ZIP q,� 7 <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 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,Standard4S',,TATdFEDEL ws.APPLICANT'S SIGNATURE:' L DATE:PROPERTY/BUSINESS OWNER❑ /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 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: a(CA ✓1 C Vtk&L<— RECEIVED <br /> COMMENTS: tiCin l/—1 �1\ n <br /> W oc*r 31 zoos <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: \ ir]n (-),/V-V" EMPLOYEE#: DATE: • <br /> ASSIGNED TO: v`��J�t Y"7Gy EMPLOYEE#: DATE: l,J�y�\� \7 <br /> Date Service Completed (if already c(:mpleted): SERVICE CODE: P I E: (l0 O I <br /> Fee Amount: a� �� J Amount Paid a Payment Date <br /> Payment Type Invoice# Check# Received By: �\ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />