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SAN JOAQuI,J COUNTY ENVIRONMENTAL HEALTHOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ PEIj/aTOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <*I 1I / <br /> SITE ADDRESS /j/ <br /> dStreet Number Direction �reet Nam Ci " ,\ ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Cam Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> j--1 - Co <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , CHECK if BILLING ADDRESS <br /> BUSINESS NAME / _ L / PHONE# EXT. <br /> L/ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY /-a 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 /> 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.F ER la s. <br /> APPLICANT'S SIGNATURE: - DATE: % j <br /> PROPERTY BUSIN�LICANT <br /> &L OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the Same time It Is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: oo o i, ' ( r <br /> COMMENTS: OCTO 2016 <br /> SAN JOAQ(JIN HEgT;"OMEN AL""' <br /> OE�'A RTMFN.I <br /> ACCEPTED BY: !J / �/� 1/ �✓ EMPLOYEE#: DATE: jL3 <br /> ASSIGNED TO: i✓- ( L w` G r� bitz EMPLOYEE#: DATE: `Ir� <br /> Date Service Completed (if already completed): SERVICE CODE: SC,o t j P 11:' 1 <br /> Fee Amount: C� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />