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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V-,�4a\J Vzkv-- ov W(j <br /> OWNER/OPERATORC CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Y"" Street Nar,a 1` Cit 6 i Codei" <br /> HOME or MAILING ADDRESS (If Different from Site Address) Ll 3 b <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 3 <br /> PHONE#t EXT• APN# LAND USE APPLICATION# <br /> (2-61) G•Z 3 _I b <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `7 PHONE# EXT. <br /> HOME Or MAILING ADDRESS ��r� 1 � F `A� i� FAx# <br /> CITY STATE ZIP Z-7 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DA'rEt j 3611 q <br /> PROPERTY/BUSINESS OWNER 1 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. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JA <br /> IV N <br /> G��a►� o, ovj,,, Jp a%jo 30 202 0 <br /> N�Ty p HMFNuNry <br /> EpgRrMFNT <br /> ACCEPTED BY: EMPLOYEE#: 00DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I J QU Amount Paid �J Payment Date <br /> o , uL� <br /> Payment Type Invoice# Check# b " 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��o Iu ZSR t <br />