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SAN JOACI COUNTY ENVIRONMENTAL HEALTH LiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S(Z )0 -7ugaa <br /> OWNER/OTOR <br /> CHECK If BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS o �1 'C]U <br /> �t Number Direction L S r�Nam!- 't 1 � Zi-Cn_� <br /> HOME Or MA INGADDRESS (If Different from Site Address) <br /> - a � JT. 2 dJv J <br /> �eEt Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 75"- Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATfON CODE <br /> RVICE REQUESTOR <br /> REDUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Y PHONE# EXT, <br /> HOME Or MAILING ADDRE FAX <br /> CIN ATE ZIP / <br /> BILLING ACKNOWLEDGEMENTe:-I;t undersigned property or business owner, operator or auzfiorized 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 <br /> ,/at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F4KRAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPEfA TO /MANAGER OTHER AUTHORIZED AGENT ❑�— <br /> If APPLICANT IS not the BILLING PARTY proof authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property localod 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: T=cm ve V1 C 2 C- <br /> COMMENTS: ,Y <br /> HsF ,/OY <br /> � tJ'10 �c <br /> AqT � T1' <br /> liy <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3-11 n <br /> ASSIGNED TO: I \�.�— � Z— EMPLOYEE#: DATE: <br /> r1 _ I <br /> Date Service Completed (if already Completed): SERVICE CODE: O PIE: / <br /> Fee Amount: Amount Paitl /3o �LI) Payment Date <br /> Payment Typen5� Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />