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SAN JOAQUP"f�bUNTY ENVIRONMENTAL HEALIVEPARTMEN'I' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS %-+Lk QL%J 0, ox't� 'b TLq <br /> Street Number Direction Street Name Cit 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 /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> ti <br /> BUSINESS NAME PHONE# EXT. <br /> 20 ) 44—3 <br /> HOME Or MAILING ADDRESS FAX# <br /> r<t► .� (tot) — 3 - <br /> CITY STATE clor ZIP <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 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: c—,,,'I -4;- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PART)',proof of authorization to sign is required Tirle <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. D <br /> TYPE OF SERVICE REQUESTED: TOO L d-4t Aep DEC_ <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> " . � .:; JUN - 32010 <br /> V + W a W <br /> �v R 0 SAN NVIRONMENTAL <br /> ACCEPTED BY: VE C EMPLOYEE#: 03Z/ WE / 3 [Q <br /> ASSIGNED TO: E ,�l EMPLOYEE#: V? DATE: t� �l <br /> Date Service ComPlete,cll (if already completed): SERVICE CODE: J! ZZ P/E: Z <br /> Fee Amount: �3-). Amount Paid 3 O � Payment Date L 3 <br /> Payment Type v/ Invoice# Check# 3 � S S Received By: (y; <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />