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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST )k <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' oo O <br /> OWNER/OPERATOR ` <br /> r 1)&)A <br /> � , 1 /� � � CHECK If BILLING ADDRESS <br /> FACILITY AME 1 ' <br /> vs' is <br /> SI ADDRESS e <br /> D 5- Street Number Direction Street Na/mVN !/ d Cit / ZJi Code`E' <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> ITY TATE IP <br /> PHONE# EXT APN# LAND USE APPLICATION# C.` <br /> PHONE#2 EXT. BOS DISTRICT LL0C_,&CODE <br /> © "�.1� 1 UA <br /> CONTRACTO / SERVICE REQUESTOR F JO,4 N <br /> Col I.- <br /> REQUESTOR V k _/ N[��p N <br /> G � G CHECK If BILLING Dpi <br /> BUSINESS NAME PHONE( EXT. <br /> HOME or MAll DRESS FAx# <br /> l i( ( ) <br /> CITY fj � 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 appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S E and FEDERAL laws.APPLICANT'S SIGNATUR G /7DATE: 9'4a <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: o 8 — — I�f (^ n�f� g'. 30 0Yyl <br /> �/eGp+-c��cf�u- <br /> Pe r��yVli1 4 2.3 q- <br /> -ACCEPTED B EMPLOYEE#: DATE: 0\\\,& 2� <br /> ASSIGNED TO: ` ` ` ` EMPLOYEE#: DATE: C:I\`\S( <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: (0 05 <br /> Fee Amount: 2— Amount Pai 16.20� Payment Date 9 !$-2-3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />