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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> OWNER/ IW <br /> CHECK If BILLING ADDRESS <br /> I A617FACILITY NAME <br /> 2 <br /> SITE ADDRESS <br /> Street Number I Dlreetlon Street Name City Zip Code <br /> HOME or MAILING ADDRE S If Diff ent from Site Address) <br /> 00 S Street Number Street Name <br /> CITY STATE ZIP <br /> e a <br /> PHONE#f Ext. APN# LAND USE APPLICATION# <br /> (-9og) Q <br /> PHONE#2 En. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST O D� I/Z— <br /> ,e '/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# _ Ex , <br /> v <br /> HOME or MAILING ADDRESSFAX# <br /> 0o n ( ) <br /> CIN ST TE ZIP 75"3�— <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 <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 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: <br /> COMMENTS: <br /> .�.� c <br /> A OCC n <br /> Ck> 4W <br /> 1,70 <br /> �oep ft <br /> WAL <br /> ACCEPTED BY: V l/q /n EMPLOYEE#: 01y DATE: 12-ASSIGNED TO: (/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q u/ PIE: <br /> Fee Amount: f vu Amount Pat s� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />