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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r c-e S- Ore- a A Dazs l S SQ 00' 125 <br /> OWNER/OPERATOR - <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME , <br /> SITE ADDRESS L N YY\CtiV� t 1 T n 1i�� `-5 33 6 <br /> Street Number I Direction Street Name Cit �C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) VV rs C <br /> 2 Street Number Street Name <br /> CITY STATE ZIP <br /> u 9 S a--i <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT P�o <br /> CATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �`,� � 1 � � / PHONE# <br /> EXT. <br /> HOME or MAILING ADDRESS l� (� ,, lI FAX# <br /> nq <br /> CITY TATE ZIP 1 �� <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <Z — A DATE: to�G ! <br /> PROPERTY/BUSINESS OWNERM 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: -';�Ood CMW ham, 1' <br /> COMMENTS: • <br /> s <br /> 9 <br /> /y�FVMr��tiyco <br /> y�F,oq FhT UHTY <br /> ACCEPTED BY: �f, EMPLOYEE#: DATE: — (1—'— I T <br /> ASSIGNED TO: C EMPLOYEE#: DATE: <br /> Date Service Completed (if ready comp) ed): SERVICE CODE: �� PIE: IVOZ <br /> Fee Amount: f�2 Amount Paid ayment Date 1� 9 <br /> Payment Type Sp1 — Invoice# Check# rj �Z 3g Rec ved y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ��G y 7,/4 "Z 7 6- <br /> .S <br />