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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> loo ow I <br /> OWNER/OPERATOR <br /> •1 L- ,a / CHECK if BILLING ADDRESS <br /> FACILITY NAME i V>o-)—A/ ,&/ <br /> SITE ADDRESS�q—�h // �1 p I V C�45-V L I ' S Number Direction ✓ Street Name / �i Cit ZLJCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 34,7 1"�t Gf/1� S l OOZE Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ^ ExT• APN# LAND USE APPLICATION# <br /> (ZE)y ) x - s� O� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> S- ^ �� CHECK If BILLING ADDRESS <br /> �T <br /> BUSINESS NAME PHONE# r ExT <br /> HOME or MAILING ADDRESS FAX# <br /> o f T 9 S-3 ( ) <br /> CITY STATE 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 <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: DATE: O/ " 3 ._ Z 1 <br /> c <br /> PROPERTY/BUSINESS OWNER) OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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. p <br /> TYPE OF SERVICE REQUESTED: RF Nj` <br /> COMMENTS: <br /> JAA/ 03 <br /> �j� � r`' ten►✓oA Z422 <br /> QUINFpARMIM <br /> e <br /> ACCEPTED BY: EMPLOYEE#: j DATE: 2 n <br /> ASSIGNED TO: EMPLOYEE#: l�'1�7 DATE: �J �y <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: �U <br /> Fee Amount:, U� Amount Pai U,;q Payment Date _ <br /> Payment Type Invoice# Check# `� Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />