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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH idEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r..�GX-1 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SIT <br /> E ADDRESS <br /> Street Number Dire ion treet Name v Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST R <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> /t✓✓j /�L C --?/- r' <br /> HOME Or MAILING ADDRESS FAX# <br /> --rW ?z5:�) /- 1 c� <br /> CITY 4� STATE ZIP-7!5; <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,Standar ,-S`rATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE.:{ •'2� _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENN'�J <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 ENVIRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: d t nvq clke4 RECEIVED <br /> COMMENTS: <br /> AUG 2 e 2014 <br /> HAN JOAQUIN COUNTY <br /> AL <br /> WEA A N Ibt f*AEUNTMENT <br /> ACCEPTED BY: ���t� EMPLOYEE#: DATE: 7 2 /V <br /> ASSIGNED TO: / A, EMPLOYEE#: DATE: 7 <br /> Date Service Completed (if already completed): SERVICE CODE: } P/E: (�(� <br /> Fee Amount: 3�C Amount Paid Payment Date / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />