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Ak SERVICE REQUEST <br /> Type of Business or Property Wr FACILITY ID# <br /> SERVICE REQUEST# <br /> 0 oU�So 0 <br /> OWNER/OPERATOR <br /> LnA en <br /> .CHECK if BILLING ADDRESS <br /> FACILRY NAME <br /> SITE ADDRESS <br /> Street Number 0 95216 <br /> Direelion <br /> Street CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY A STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXr• - BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NINIEFLt -44 PHONE# — ET' <br /> T ' tne <br /> WtM <br /> HOME Or MAILING ADDRESS FAX# <br /> I ) `bl-6 5A 2 <br /> CITY STATER) zip q <br /> c 11 14 r3�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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I1�1 1k DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT finnt45e,n(Uf(�(1 ) <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 rty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envir a assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an It IS <br /> provided to me or my_representative. <br /> TYPE OF SER UESTED: e� PAYMENT <br /> COMMENTS: IS& RECEIVED- <br /> JUN 12-2012 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEDBY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:< PIE: <br /> Fee Amount: Amount Paid Payment Date 6 <br /> Payment Type Invoice# Check# n Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />