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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> t\ /t ,t c CHECK If BILLING ADDRESS <br /> FACILITY NAME Y\ U <br /> SITE ADDRESS <br /> 240 Street Number Direction "� treat Nam" e �" CR Zi Code <br /> HOME or All ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR� i �c lr/ L CHECK if BILLING ADDRESS <br /> BUSINESS NAME t 1 v (� PHONE# 1D� ^ EXT, <br /> HOME or MAILING ADDRESS FA v <br /> C'� (" �) 0 z1 - I <br /> CITY \ ` —t I gou5e <br /> STATE ZIP <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 applicat and that the work to per rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST nd FEDER aws. r� J <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MA GER OTHERAUTIIORIZEDAGEN7 <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 <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: <br /> COMMENTS: R ci <br /> ENSJOA co, <br /> ACCEPTED BY: U'r�C ` EMPLOYEE#: J7rqL-rH IV (+ <br /> ASSIGNED TO: �a��(t y S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ZZ PIE: l (, <br /> Fee Amount: - � Amount Paid Payment Date J <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />