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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busin ss or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> n �`, , � CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS` �/�n �` / �7 <br /> Street Number Direction l—Street Name <br /> HOME or MAILING ADDRESS SS (If Different from Site Address) V ( 7 n / <br /> C 7- r'1 Street Number I /v Street Meme 1J <br /> CITY C E STA „ ZIP <br /> TE S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <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 rm. <br /> I also certify that I have prepared this ap ' ation a at the or o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard TATE a DERAL la <br /> APPLICANT'S SIGNATURE: DATE: �� D <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 anq�At the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: / Q/� SAH Q 20 <br /> 08 <br /> ,0' A, <br /> MFNTq�NT,q���Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> A 01 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid 1 O PaymentDate <br /> t , <br /> Payment Type Invoice# Check# L lC Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />