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SAN JOAQT OUNTY ENVIRONMENTAL HEALT XPARTMENT <br /> %i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> L r p-- CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS .•`` �� <br /> Street Number Direction eet Name A lv Cit :::[:]i Code <br /> HOME Or MAILING ADDRESS (If Different from Site/Address) �) C �'tr�et NaYn�� <br /> / Street Number ✓ ✓�(- e <br /> CITY 419�z Je� 0 STATE ZIP <br /> /Z <br /> PHONE#1 ExT. APN# LAND USE APPLICA ION <br /> c,�7 PHONE#2 EXT. BOS DISTRICT LOCATIO ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> a CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> 6�1h) &02& 126CIdi A�6621 0(i <br /> 5, 34ze- <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 4 <br /> 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l DATE: L7 Qt� <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: A <br /> COMMENTS: PAY <br /> RECEIVED <br /> cot, <br /> 2 9 2008 <br /> OC1 13 <br /> T a; <br /> SAN JOAQUIN COUNTYft : <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMP DATE: <br /> ASSIGNED TO: EMPLOYEE#: D DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: J�4�2 ,S� Amount Paid �"Z�_ Payment Date (,b I <br /> i „� <br /> Payment Type Invoice# Check# ( Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />