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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> got oyqqSo <br /> OWNER / OPERATOR <br /> Co, CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 1 IC IJ <br /> 11 0 , 1 Gn . <br /> SITE ADDRESS <br /> ?51s S� 5 SZJ f <br /> n � L UV1 <br /> Street Number Direction � / bC Street Name City Zh3 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 /> ( sib ) 711 � Os3 <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> R ` ) ` � CHECK if BILLING ADDRESS <br /> r^ 1 w >n <br /> BUSINESS NAME � <br /> PHONE # EXT. <br /> HOME or MAILING ADDRESS FAX # <br /> CITY Sb �� , to STATE CA <br /> ZIP Z -) yr <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 /> also certify that I have prepared this application and that the wo t e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE : il �l5j 1P <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT �I <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 t0 me Or <br /> my representative . <br /> TYPE OF SERVICE REQUESTED : V - J <br /> COMMENTS : <br /> ti j N '/?0 QUTA ��18 <br /> V C <br /> gR����Y <br /> ACCEPTED BY: EMPLOYEE # : DATE : (2 <br /> Q ^ I � <br /> ASSIGNED TO : l \/ (^ V/ EMPLOYEE # : DATE : ` ,lac 1 <br /> Date Service Completed ( if already completed ) : SERVICE CODE : �� PIE : a3 D2 <br /> Fee Amount : Amount Pai [ �, I> Payment Date <br /> Payment Type / Invoice # Check # 3 7�� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />