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SAN JOAQUIN COUNTY ENVIRONIIIENTAL HEALTti DEPARTIIIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V11 E-FP`OPERATOR �� Y 1 CHECK if BILLING ADDRESS <br /> FACILITY NAME x �— <br /> SITE ADDRESS I OI S KJ -� MAN ( �� Q 1573 <br /> Street Number Direction StreetNameCirt �C�I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> `� �' � C� e " G� Street Number Street Name <br /> CITY CG STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zoe ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> 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 yvl FEDERAL laws. Z <br /> APPLICANT'S SIGNATURE: DATE: �7�C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 <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: U E T Co Ns; U ( 4} -i lam) PAYUIEN <br /> COMMENTS: <br /> MAY 0 3 2007 <br /> SAN TM <br /> V RONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: /11 <br /> ASSIGNED TO: ��� J EMPLOYEE#: 3 DATE: S J G <br /> c <br /> Date Service Completed (if already completed): SERVICE CODE: o6l PIE: 2 31 <br /> Fee Amount: 01 S 0 Amount Paid S c5� Payment Date —� <br /> Payment Type lI �- Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />