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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i 5� ou,& <br /> OWWR I OPERATOR <br /> Z- 7 a CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME j c <br /> SITE ADDRESS ZO S I ! DJ G KA MV I/�D UDO Oi rjZt� <br /> Street Number Dlrectfon Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different o Site Address) <br /> - Street NumberT Street Name <br /> CITY� STATE ��� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (M ) Ci fl <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> RE €sTaIII <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAMEt y PHONE# Exr. <br /> HOME Or MAILING ADDRESS �/' FAX# <br /> CITY 6o <br /> STATE ZIP /I L5 i •7 /j <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: ///"X)"� DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR f56ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAppucANTis nor the Blaxg PARTY,proof of authorization to sign is required Tide <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 envirA sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabl P126 01time it is <br /> provided to me or my representative, r�(CC �D <br /> TYPE OF-SERVICE REQUESTED; \)ek�ctc vie4vw\.- DEC 0 8 20 <br /> COMMENTS: SAN JOAQUIN COUNTY <br /> EhMRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: _ EMPLOYEEM DATE:I� r� <br /> ASSIGNED TO: C �• EMPLOYEE#: DATE: cw <br /> Date Service Completed (if already completed): SERVICE CODE: o`n P I E: U <br /> Fee Amount: 1 7 Amount Paid s Payment`Date <br /> Payment Type O _ Invoice# Check# Received By: L <br /> EHD 48-02-025 �,D'h{' 11 7 7�f S Lj f SR FORM(Golden Rod) <br /> REVISED 11117/2003 fv f(; 1 i <br />