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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property I- FACILITY ID# SERVICE REQUEST# <br /> 00 <br /> OW,�1ER/OPER ,R. � <br /> ( `� ` . CHECK if BILLING ADDRESS <br /> kCA �Ag- CV\QX\6e-Z- <br /> FACILITY NAME r ` <br /> V YA � <br /> SITE ADDRESS _ CA 1 1 j1 )� �w <br /> Street Number Direction Street Name ` ` �Z y o e <br /> H E Or MAILING AD ESS (If Different from Site Address) <br /> CAI LAIC Q� Street Number Street Name <br /> CI � C STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> Ad -3 0 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> J 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 applici d that It work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST a DER L la S. <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY/BUSINESS OWNER IG OPERATOR/IM[AjAGER ❑ OTH AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proo o aUTPfis ton 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 a8sesstnent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same ti"Itis prdvV ded t0 me Or <br /> my representative. , <br /> TYPE OF SERVICE REQUESTED: F.vA �r ��� T.�•; y,` ` 1 "'( j <br /> COMMENTS: `SAN JOA QUr <br /> fJa✓t,) 01, /O pfraror tat veJkl<..le. ti V/�� eCO LNC <br /> pART/yFNT <br /> ACCEPTED BY: MW�Q EMPLOYEE#: DATE: C{_(q-(7 <br /> ASSIGNED TO: �`�L�w Z- EMPLOYEE#: DATE: 4-Lcl-(7 <br /> Date Service Completed (if already completed): SERVICE CODE: i; I PIE: <br /> (,v <br /> Fee Amount: `f Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />