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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> f /Vi <br /> CHECK if BILLING ADORES <br /> iJv��-c<<n <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction Street Name <br /> city Zip 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 /> ( ) <br /> CONTRACTOR/ SE I RVICE REQUESTOR <br /> - REQUE TOR _ �� <br /> L--'BUSINEss <br /> �'l fin veil C�.i CHECK if BILLING ADDRESS❑ <br /> NA f ( 11 PHONE# EXT. <br /> H rE or Mau ING ADD ESs� FAX <br /> CITY / <br /> (/ STATE /L� 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 FEDERAL laws- <br /> ---IiAPPLICANT'S SIGNATURE: ,, ��� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER C,-1' 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 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: S— <br /> COMMENTS: <br /> HE Fhy�R00, 41 fes <br /> 'Y �«,F�C�G 'V <br /> ACCEPTED BY: '7 EMPLOYEE M DATE: <br /> ASSIGNED TO: % ,, EMPLOYEE M DATE: <br /> Date Service Completed (i already completed): SERVICE CODE: j'�S -' PIE: � r <br /> Fee Amount: Amount Pal 376.6 bPayment Date d <br /> Payment Type Invoice# Check# t�E Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />