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SAN JOAQUW COUNTY ENVIRONMENTAL HEALTH DtNARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C Fit U ale FA cc <br /> W R/OPERATOR <br /> CHECK If BILLING ADDRESS©/ <br /> FACILITY NAME U� . <br /> SITE ADDRESS / <br /> S Street Number Direction Oro Street Name r J C i n -Zi de <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 /> Qc�> <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <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, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <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 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 <br /> me time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: Fo 1Cr/Nl kI�(G✓) `V I�f�-1} <br /> COMMENTS: r A D <br /> Sid 6 2018 <br /> y4Flys gQIJIN <br /> 4ry0'0,V COUNn, <br /> ACCEPTED BY: A EMPLOYEE#: DATE: <br /> ASSIGNED TO: �n U EMPLOYEE#: DATE: 7^6-{ <br /> Date Service Completed (if a ready completed): SERVICE CODE: i PIE: <br /> Fee Amount: C� Amount Paldr C , Payment Date <br /> Payment Type I�f� .. Invoice# Check# Received By: % <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />