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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# g� SERVICE REQ yEST# <br /> O OPERATOR <br /> I CHECK If BILLING ADDRESS <br /> ACUITY NAME <br /> SITEADDR ZJ�A /' _ <br /> Street Number Direction Street Name LCI(/�t� ZiCode <br /> 95 <br /> HOME Or MAILING ADDRES (If Differ e It from Site Address) <br /> Street Number Street Name <br /> STATE ZIP T <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRA R SERVICE QUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS N E PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> s w ( 0 3 <br /> CI STATE ZIP <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 plication and that the work t e p ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: - <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN not the BILLING PARTY,Proof Of authorization to sigh 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 /> t0 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: (� PA <br /> YMNT <br /> COMMENTS: <br /> MAY 0 9 2017 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ska EMPLOYEE#: DATE: <br /> ASSIGNED TO: r l I_ f. .�-.` EMPLOYEE#: DATES-9 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid 3 C( a.90 Payment Date j _ r " 7 <br /> Payment Type tr �, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />