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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7 OWNER I OPERA/T' J OR ^/Q <br /> 1 N 4� V6,1U CHECK if BILLING ADDRESS® <br /> FACILITY NAME 1 <br /> SITE ADDRESS `'Gr,�` p 5 <br /> Street Number Direction Street Name cAt ZIP Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> I Street Number Street Name <br /> CITY STAT ZIP <br /> YG( S <br /> PHONE#1 EXT. APN It LAND USE APPLICATION# <br /> G 50 S Ci <br /> PHONE�I2 — 1 y ExT. BOS DISTRICT LOCATION CODE <br /> ZC) <br /> 1L yl CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �G,el CO CHECK If BILLING ADDRESS <br /> BUSINESS NAME —17(L) Y PHONE Ext. <br /> HOME Or MAILING ADDRESS C-� FAX# <br /> v V� ( ) <br /> CITY STATE STATE Ck ZIP 9 <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 certiiy that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TAT and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURr.rE::/ DATE: (O <br /> PROPERTY/BUSINESS OWNER MIERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 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. d <br /> TYPE OF SERVICE REQUESTED: il�7co� 4�I/)((„ <br /> COMMENTS: E/V,F <br /> OOT D <br /> SqN JOA <br /> fiy� QUf <br /> HfAtT�go Aq TqtN�Y <br /> ACCEPTED BY: 'J: . , EMPLOYEE#: DATE: <br /> rh, V3 <br /> / <br /> ASSIGNED TO: n \1 ' �11t- EMPLOYEE#: DATE: )00 )3 <br /> Date Service Completed (if already completed): SERVICE CODE: O(, PIE: <br /> u+ i <br /> Fee Amount: 1'?� Amount Paid/3b U Payment Date /�13 h1 <br /> Payment Type�G,Y/L� Invoice# Check# Receive6 Byre_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />