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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 60AT,ra n <br /> FACILITY NAME <br /> A�Ile✓ Ew��`�etiv l <br /> SITE ADDRESS <br /> Street Number Direction �t Street ame Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / Street Number Street Name <br /> CITY STATE ZIP <br /> A vet✓�>1 G/4 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 385-00--tc-'L - <br /> ! PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It 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: 1, 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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIFR 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: �)a—7c9 6 r <br /> 014 _+NVZ- <br /> ACCEPTED BY: �_1 1 EMPLOYEE#: �j DATE: <br /> ASSIGNED TO: L( 1 EMPLOYEE#: 6 O DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: — P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />