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%-I,r 11-' <br /> SAN .IOAQ <br /> 1J11V COUNTY ENVIRONMENTAL. HEALTHPARTMENY <br /> SERVICE REQUEST <br /> Type of Business or Property =FACILITY ID# SERVICE REQUEST# <br /> o PC <br /> 1�4�1� ���p��2� <br /> OWNER I OPERATOR CHECK if BILLING ADORESS❑ <br /> r�r <br /> FHUTY NAME <br /> C>L r <br /> nSITE/ADDRESS tJ �O C)D4 Oy1 10(11 4 0 `" <br /> Ala Street Number Direction K�� O� Str t Name cityZi Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Namber Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> USENESS NAME PHONE# Exr. <br /> ► � V $7 <br /> HoME.or MAILING ADDRESS FAx# <br /> S nc!L AvQ- ( ) <br /> CITY T rE Y-\ ZIP C1 P) <br /> 1 C� <br /> b J <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 64 DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment inf rmation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 it i5 available and at the same time It IS provide ^^ Qr <br /> my representative. [[ E <br /> TYPE OF SERVICE REQUESTED: rood ,i I/K,I ()n N CQ <br /> COMMENTS: SAN�Q O�U <br /> N FNy�0U1 y u <br /> �44 IL <br /> r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: LIA10t. ftmwah J <br /> EMPLOYEE#: DATE: <br /> Date Service Comp ted (if alreadycompleted): SERVICE CODE: S ( PIE <br /> Fee Amount: [ Oi Amount Paidr ,B�06 Payment Hate <br /> Payment Type Invoice# Check# o Z I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />