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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK IfBILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESS �J�� � �� J�Z tel 0,� r'o qs Z I L) <br /> Street Number Street Naine Z10 Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Streot Name <br /> CITY STATE ZIP <br /> PHGNE#1 EXT, APN# LAND USE APPLICATION# <br /> + 7 ) -73 <br /> PHONE#2 EXT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS D <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> i ) <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, <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. <br /> APPLICANT'S SIGNATURE: A DATE: :22...- ZZ <br /> PROPERTY/BUSINESS OWNER OPERATOR/ti1ANA :FR ❑ OTHER At T'NORI7.ED AGENT❑ <br /> If APPLICANT is not the BILLING f ARTY 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/si e assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL.TIi DEPARTMENT as soon as it is available and at the tt is <br /> provided 10 me or my representative. r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 1 q <br /> h�TH EpMFN�NrY <br /> �M71 <br /> ACCEPTED BY:` ( / /) a EMPLOYEE#: DATE: ? /i <br /> ASSIGNED TO: v 1 La`J EMPLOYEE#; DATE: <br /> Date Service Completed (if already,completed): SERVICE CODE: ](To Z P!E: 0 <br /> Fee Amount:-IL ��� Amount Paid i�Ja Payment Date <br /> Payment Type Invoice# Check# 8 �G(C� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />