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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # ^SERVICE REQUEST # <br /> �J (kw <br /> OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> SITE ADDRESS hCtLate <br /> Street Number Direction Street Name Cit Zi 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 /> ( ) 0 H <br /> PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR9 , At o t ( , �t n CHECK If BILLING ADDRESS <br /> VA <br /> BUSINESS NAME <br /> Le. S-1itSR( � ^ l A, ( ✓ PHONE # Ems' <br /> u ( �w� ;X 3 C�N 3 V <br /> HOME Or MAILING ADDRESS FAX # <br /> L t7CLQ-� P1,4 Lu ( ) <br /> CITY i -p � s� STATE !Z 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 j <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 , <br /> APPLICANT ' S SIGNATURE : tgOLL: o" � ' / `�`'-'- ` � � DATE *y <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT lel & u.t.aw <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 ; U u PAYMENT <br /> COMMENTS : AUG 2 7 202' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY : M . EMPLOYEE # : DATE : / <br /> ASSIGNED TO : , ' //? ` �d�v�J EMPLOYEE #: DATE : <br /> Date Service Completed ( if already completed ) : ;SERVICE CODE: , � PI E : 2��� <br /> Fee Amount : � Amount Paid Payment Date <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02 -025 SR FORM (Golden Rod ) <br /> 07/ 17/08 <br />