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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST. <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> nater k-� CHECK If BILLING ADDRESS <br /> FACILITY NAME Pad <br /> SITE ADDRESS <br /> Street Number Direction C, <br /> - Str et�N!me �� CI Zi C�odev <br /> HOME or <br /> MAILING ADDRESS 1(If Different from Site dress) <br /> TZd Street Number Street Name <br /> CITY STATE ZIP <br /> C Z3 <br /> HONE#1 EXT. APN# > LAND USE APPLICATION# <br /> PHONE#2 T• BOS DISTRI T LOCATION CODE <br /> c ) z3�- alp 8 � �ti-fe►� � l a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r CHECK If BILLING ADDRESS <br /> ra�l <br /> BUSINESS NAMEc PHONE _ EXT. <br /> G <br /> HOME or MAI LI AlDRESS <br /> C Fax# <br /> CITYC $T E ZIP 5; 5 75 I <br /> BILLI G 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 law <br /> APPLICANT'S SIGNATURE: l/� �� ` DATE: 5/�/ <br /> PROPERTY/BUSINESS OWNEQ� 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 Same time it is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: —E► a1 <br /> REFCEivrmn <br /> COMMENTS: CD, <br /> MAY Q 7 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAIL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I Ica EMPLOYEE#: DATE: <br /> ASSIGNED T0: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: U4, P l E: r 4,p <br /> Fee Amount: (� — Amount Paid J �, Payment Date ,- <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />