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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> s S tri )0 /�3 q fq )Ooqt ) ;,T <br /> OWNER / OPERATOR <br /> �c��Q '� � J U v (o- O 5 CHECK if BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> SITE ADDRESSl � SEvc_( � <br /> Street Number Direction S et Namo City Zip Code <br /> HOME or MAILING 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 ' CHECK if BILLING ADDRESS <br /> A CSU WLL ( Aca , tA <br /> BUSINESS NAME t PHO E Ems' <br /> �J-COQ (4D� <br /> HOME or MAILING ADDRESS FAX # <br /> 6 Q o <br /> CITY 5e, l:STATE (?4't ZIP <br /> I, <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 /> 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 . I l <br /> APPLICANT ' S SIGNATURE : �jj ��( u V . /U-CLGi Lu DATE : /� <br /> PROPERTY / BUSINESS OWNER [3OPERATOR / MANAGER [3 OTHER AUTHORIZED AGENT � l� l CLP D t�` (t/ <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 to me Or <br /> my representative . PA <br /> / / <br /> TYPE OF SERVICE REQUESTED : C � sT/ / ' vl r� P`FPit <br /> COMMENTS : <br /> JOA <br /> EP 22 20 <br /> ,, <br /> HEALTH 0 NMi CAL / y <br /> ARTNIE <br /> ACCEPTED BY : /1 L? ` �/ 1 `� EMPLOYEE # : DATE ; e9112,1 C�7� <br /> � G ( <br /> ASSIGNED TO : � `?Q �d f� EMPLOYEE #: DATE : l Z <br /> Date Service Completed (if already completed) : SERVICE CODE , e7 - 2 q P / E : DO <br /> Fee Amount : !J— CD Amount Paid L Payment Date <br /> Payment Type Invoice # Check # S Received ' By: <br /> EHD 48 -02 -025 SR FORM (Golden Rod ) <br /> 07/17108 <br />