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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines r Property cry,) FACILITY ID# SERVICE REQUEST# <br /> Ad 10&/Un a 1 ��I " 000 3� 6R-00 �fIf! o / <br /> OWNER/OWER#OR <br /> hp <br /> ffvo <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME /� \� <br /> 11 6 12M <br /> SITE ADDRESS `f 'J <br /> Street Number Direction "� Street Name Cd <br /> HOME Or MAILING ADDRESS (If Different from Site Address) &&Z <br /> ` <br /> Street Number fi&tre t e <br /> CITY ^ �-' � SATE ZIP <br /> PHONE <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / ^f 1 <br /> J� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE4) <br /> HOME or MAILING ADDRESS FAX# I_ ) <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, ATE and FEDERAL laws. <br /> / --2-76� <br /> APPLICANT'S SIGNATURE: lk I <br /> / DATE: <br /> PROPERTY/BUSINESS OWNER ElOPERATOR/MANAGER 1:1 OTHER AUTHORIZED AGENT t' <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 avai 4We and at the same time it is <br /> provided to me or my representative. �� Q <br /> TYPE OF SERVICER ES ED: <br /> COMMENTS <br /> AA <br /> POv�N ENS��� <br /> V� SP�N�No QPP�M <br /> N N� <br /> ACCEPTED BY: EMPLOYEE#: CyJ DATE: -)k S-- <br /> ASSIGNED TO: EMPLOYEE#: t ) DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: vvi P 1 E: 2 7f <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />