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SAN JOAQ UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property LL _ FACILITY ID# SERVICE REQUEST# <br /> C STo.11 v �ti l (LCJ lV (a -7 <br /> OWNER/OPERATOR ix3- <br /> Ic - r J; K If BILLING ADDRESS <br /> FACILITY NAME f l <br /> V. <br /> SITE ADDRESS I �7 R ��j� �—(L� �.�1_ �-� CSS 3 `7� <br /> Street Number r coon L Street Name ( l/ Cit 1 Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1 5 Street Number "� Stree Name�� <br /> CITY <br /> z 3 STATE zip <br /> p7 <br /> PHONE#1 EXT. APN# z 1o Z(3-- LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work t e per or ed will be done in accordance with all SAN JOAQIIIN <br /> COUNTY Ordinance Codes,Standards, STATE a ED . At. ws. <br /> �n <br /> APPLICANT'S SIGNATURE: DATE: l �� <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER OTHER AUTHORIZED A(;ENT❑ <br /> ff.-IPPLICANT is not the BILLING PARTY,pro f of autkorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: "p J ! =.CEIV5D <br /> COMMENTS: <br /> APR 2 0 201 <br /> JoAQUAN COUNTY <br /> w I RON MENTAL <br /> H 0 EWTM ENT <br /> ACCEPTED BY: � •` —Z_ EMPLOYEE#: DATE: 4 "Z C) I ( Z <br /> ASSIGNED TO: tiJ t <-- f EMPLOYEE#: / �!1 DATE: -� I Z C) <br /> Date Service Completed (if already completed): SERVICE CODE: Sz-3 P/E: loo t <br /> Fee Amount: 37 s Amount Paid 3? Payment Date Lt �O Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />