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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 52 00 " <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> /Street NubEr Diren <br /> mctioStreet Name 3 3r City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S 5 fj(r Street Number Street Name <br /> STATE ZIP <br /> PHONE#I <br /> EXT. N# LAND USE APPLICATION# <br /> AP <br /> QO ) - <br /> PHONE#2 EXT. BCIS DISTRICT LOCATION CODE <br /> - sy 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 or <br /> 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, STA ,and FEDERAL laws. <br /> APPLICANT'S SIGNAT I DATE: 2— '7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/11IANAGER ❑ 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 /> 4E:j�y��y�c,,�c <br /> COMMENTS: —" RECEIVED <br /> JUL 1 2 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: I DATE: <br /> ASSIGNED TO: EMPLOYEE#: v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ( � �. L Amount Paid O r Payment Date 11 O <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />