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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACT TY ID# RVICE REQUEST# <br /> n 'a� h4aqww i <br /> OWNER/OPERATOR \ 11 <br /> CHECK if BILLING ADDRESS� <br /> FACILITY NAME �\ 11 1 \yah e?nO '10y'�l <br /> SITE ADDRESS ��' �i ^' �11a/ In SJ1 I • I`T �Q�.�f.C� <br /> SUeel Number Olrecilon Street Name C t ZI Coda <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 /> PHHONNEE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RECUESTOR I n' 't t CHECK If BILLING ADDRESS <br /> BUSINESS NAME "1 `11 / ` "l.yIYJ_�••`.'• PH�E# Em <br /> HOME or MAILING ADDRESS A 2 M I N FAX# <br /> CITY M ¢ STATE zip �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. (j / <br /> PLICANT'S SIGNATURE �� DATE: 00 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT 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 <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 /> Changc, of AUG > > ?0 <br /> yf �o UIN CO 2� <br /> Ei(Ty pEP ENtq�Tl' <br /> ACCEPTED BY: EMPLOYEE#: DATE: 11 2 NT <br /> ASSIGNED TO: EMPLOYEE#: D DATE; <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: I U� <br /> Fee Amount: Irij 'Q Amount Paid IS'a! Payment Date <br /> Payment Typed Invoice# 2..� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> QYzC�23515 <br />