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io.t� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> LQ C r� C- <br /> FACILITY NAME <br /> SITE ADDRESS � �v <br /> C,i lice <br /> 3 5 E Street Number Direction Street Name it Zip Code <br /> HOME117VAILING ADDRESS If Different from Site Address) <br /> ddress) <br /> C t L�yS Street Number Street Name <br /> CITY GCAv STATE C ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) OSS-� / ?S' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Idt` PHONE# EXT. <br /> C 20-1 9 y -1345 <br /> Ho.vir Or MAILING ADDRESS FAX# <br /> 28L5 r >NVr WC Sk (20 ) <br /> CITY C+„__ li STATE (�n ZIP �l n <br /> J t rte-l� � �-� + !CJ <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 FEDE laws. / <br /> APPLICANT'S SIGNATURE: -4DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT J9 FJYq,.YQej' <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Ili 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: <br /> COMMENTS: <br /> REC IVSD �O <br /> JUN 13 2005 <br /> SAN JOAQUIN COUNTY (� <br /> ENVIRONMENTAL r <br /> ACCEPTED BY: EMPLOYEE#: /99ATE: / O <br /> ASSIGNED TO: _ EMPLOYEE M $ DATE: lY <br /> Date Service Completed (if already completed): SERVICE�Q'\ Z I P 1 E: Q <br /> Fee Amount: Amount Paid — P yment Date /0 S <br /> Payment Type Invoice# Check�� Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />