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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FN 0 (f U3 Sr2GU7� 100 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME M !� <br /> SITE ADDRESS <br /> Street Number DIrecUor �—- � r Street Name ���C'" ✓ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SStreet Number Street Name <br /> CITY STATE zip lS <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> O l4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 6�1211 2-y <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR rJ <br /> CHECK If BILL3NC,ADDRESS❑ <br /> BUSINESS NAME GSL PHONE# xT' <br /> Q <br /> HOME Or MAILING AD ESS FAX# <br /> CITY O ) STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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, ST E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 1S 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 assessm Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr C � or <br /> my representative. ll ^^ ,/� �r g�' <br /> TYPE OF SERVICE REQUESTED: "00l/uI �J V t 60 1 e <br /> COMMENTS: f� ,{ s D �Ol <br /> I L v �dOAQU/M COIJIV <br /> NF-4t H D 4 MSN <br /> r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#; DATE: 2 3G <br /> Date Service Complet d (if already completed): ri SERVICE CODE: ✓PIE: �-Z <br /> Fee Amount: I s3 Amount Paid 13q�dZ) Payment Date �1 <br /> Payment Type Invoice# Check# l� hteceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07!17108 <br />