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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t--� -4 --�-rw,\-e"� 25 22 ?S SQ dog ZH <br /> OWNER/OPERAT <br /> r <br /> O u, YtC I� a r e- Zo�J C <br /> FACILITY NAME HECK If BILLING ADDRESS❑ <br /> 1 I <br /> N N S�3Z <br /> SITE ADDRESS <br /> Street Number 0 wtlon Street Name CI ZIv Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> cA 5 376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c'149GO q94 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> a <br /> BUSINESS NAME PHONE# EXT. <br /> tU o Uf>?Ce G 7- <br /> Hol or MAILING ADDRESSFAx# <br /> ( ) <br /> CITY - Cc STATE�v ZIP C y� <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 4- <br /> COMMENTS: I VFX <br /> sgNJUC 3 2420 <br /> N�CTy0pgM� REtiTN� r <br /> N64 <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: L r\` C` EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: b <br /> Fee Amount: <br /> Payment <br /> Paid Payment Date !' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 pp <br /> 1 I-C,`I`�L'�I�� <br />