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SAN JOAQ• COUNTY ENVIRONMENTAL HEALTH WEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i 'r U 1 <br /> 0002�� SF-OU -7ce�q(p <br /> OWNER/OPERATOR <br /> & 0 � � CHECK If BILLING ADDRESS <br /> Of <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 16. wumoer I Direction _'treet Name cl Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �) r/ <br /> StreefNumber ` \v 1 St/egtName 6 <br /> CITY C STATE ZIP frD <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (?O ) C(,<{ 7o51 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 0 CHECK if BILLING ADDRESS <br /> / BUSINESS NAMEPHONE# EXT. <br /> Te rti 1 `o <br /> HOME or MAILING ADDRESSFAX# <br /> 2- ': 4 OO e• oco( a ��� ( ) <br /> CITY 1 �p 0 STATE ZIP C� <br /> bc I /V <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 /> 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 FEDERAL laws. <br /> a <br /> APPLICANT'S SIGNATURE: j2 ae-da _ DATE: j 9 - `26)1 <br /> PROPERTY/BUSINESS OWNER❑ J OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 same time It' provided to me or <br /> my representative. "Lc YY <br /> TYPE OF SERVICE REQUESTED: O CES <br /> COMMENTS: C O <br /> sAN 9 ?016 <br /> JOAQU1IV <br /> HEAL H�E qE'V-NIL <br /> Eq►r <br /> ACCEPTED BY: �'I y EMPLOYEE DATE: <br /> ASSIGNED TO: r/ �hrS l I Z EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C O P/E. 03 <br /> Fee Amount: l 1j 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 />