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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> L/ <br /> OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ <br /> FACILITY FLAME <br /> SITE ADDRESS <br /> Sheet umber Direction kl; 16 <br /> Street Name CI i /ode <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE # ') EXT, APN # LAND USE APPLICATION # <br /> ( ) <br /> PHONE #T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR J /J 0 / CHECK if BILLING ADDRESS <br /> �/✓� r <br /> BUSINESS NAME PHONE # EXT . <br /> HOME or MAILING ADDR SS v i FAX # <br /> CITY o1 STATE l`� 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, ST/Ead FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE & / ,2 <br /> PROPERTY 1 BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT tl�t3tkL 1 . <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 /> to 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 . <br /> TYPE OF SERVICE REQUESTED : S' fj'U �c T <br /> COMMENTS ; NOV <br /> O <br /> SAN �O ?oZ, <br /> ENV/ AQU/N C <br /> NEACT H 0�pgRrME�7 Y <br /> ACCEPTED BY : n-�ri v EMPLOYEE M DATE : <br /> ASSIGNED TO : ! 1 ' L�� ' �Q j �'�rJJ� EMPLOYEE M DATE : <br /> Date Service Completed ( If already completed ) : SERVICECODE : 1, (1 _ +7G�,f- PIE: <br /> Fee Amount : j( 1 57 at/ Amount Paid U Payment Date <br /> Payment Type Invoice # Check # l Received By: <br /> EHD 48-02-025 SR FORM ( Golden Rod ) <br /> 07/ 17/08 <br />