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SAN JOAQUIN —,)UNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A o'yl� <br /> OWNER/OPERATOR <br /> D� CHECK If BILLING ADDRESS <br /> / / <br /> FACILITY NAME <br /> SITE ADDRESS S <br /> Street Number D HOME or or MAILING ADDRESS (If Different from Site Address) <br /> &06 �/��( Street Number t� Street Name <br /> CITY6hC 4 STATE ZIP <br /> !L (N't S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EiT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �h / A' //, / CHECK If BILLING ADDRESS <br /> BUSINESS NAME /`TI (/ PHONE# E"T. <br /> s329s <br /> HOMEOr MAILING ADDRESS FAx# <br /> G�D h s7 ( ) <br /> 1SZ2BCITY / (A ST E, ZIP -15227— <br /> BILLING <br /> ILLING 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 laws. <br /> s, <br /> APPLICANT'S SIGNATURE: / Yom. DATE: <br /> PROPERTY/BUSINESS OWNERRRJ?/ OPERATOR KMANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 atatYg same time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ad VV�SI� 0/ ^C� <br /> COMMENTS: JO )z <br /> G �OZO <br /> � � p� �� o Owns '' pLIIIV <br /> � M"'� <br /> ACCEPTED BY: ('0440 =EMPLOYEE#: q DATE: <br /> ASSIGNED TO: �/ i� EMPLOYEE M 3(P DATE: y fw <br /> Date Service Completevd (if already, completed): SERVICE CODE: 0(4q PIE./tiI013 <br /> Fee Amoun • Amount Paid Os Payment Date <br /> Payment Type C Invoice# I Check# Received By: <br /> EHD 48-02-025 I O �.itJg SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />