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SAN JOAQU, 20UNTY ENVIRONMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHEC if BILLING ADDRESS❑ <br /> FACILITY,NAME , <br /> SITE ADDRESS <br /> 1 S ✓>1 La t I <br /> Street Number Direction Street ame Ci Zi Code <br /> OME or MAILIN9 ADDRESS (If Diffe ent from Site Address) <br /> Street Number Street Name <br /> CITYTATE ZIP <br /> Glut C� X5241 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> e&q) 333- (" D 240 94 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> \� ll CHECK If BILLING ADDRESS <br /> 2�BUSINESS NAME f PH E ExT <br /> ' Yl,S,eS �11 3C,��- 4--06 <br /> HOME or MAILING ADDR S FAX# <br /> 2 3 v (d�) acv-1 <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 erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA an EDERAL 1 <br /> APPLICANT'S SIGNATURE: DATE: Iz 0 2-- <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: )(,-L <br /> COMMENTS: �6n a ,n _ _ O <br /> OCT 0 2 2012 <br /> / ENVIRONMENTAL HEALTH <br /> ACCEPTED BY: r EMPLOYEE#: DATE: <br /> 7� <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already com leted): SERVICE CODE: P I E:2 <br /> Fee Amount: " Amount Paid ,�5, ; Payment Date U ? <br /> Payment Type ^�+ Invoice# Check# b� Received By: <br /> EHD 48-02-025 SR FORM(G den Rod) <br /> REVISED 11/17/2003 <br />