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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 /> CHECK If BILLING ADDRESS <br /> J<QGA <br /> FACILITY NAME ���� <br /> SITE ADDRESS LO a-v\ ; <br /> C ,I P0.< <br /> Street Number Direction —` Street Name 1 City Zip Code1 <br /> HOME or MA ING ADDRESS (If Different from Site Address) <br /> Cl Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2a� 1 %-)-4-30�k <br /> PHONE#2 r EXT. BOS DISTRICT LOCATION CODE <br /> ( ��) 2 C <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C� � � CHECK if BILLING ADDRESS Uva <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS /J G G / «,y. FAx# <br /> CITY �, ��:�� STATE C�^ ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: 3` �r— r���yy// <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR IANAGER OTHER AUTHORIZED AGENT L'o. <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. <br /> TYPE OF SERVICE REQUESTED: DG� G��y/L'�' � L G I��L�� PAYM <br /> COMMENTS: <br /> MAR 1 1 2011 <br /> SAEONVRNMUiN <br /> HEALTH DEPABN <br /> ACCEPTED BY: / r�G EMPLOYEE#: t '/ DATE: <br /> ASSIGNED TO: 4�'rN EMPLOYEE#: DATE:9 7 Jk /v <br /> Date Service Completed (if already completed): SERVICE CODE: �/ P i E; <br /> Fee Amount: 7 7��� Amount Paid �( Payment Date <br /> Payment Type Invoice# (� q Check# Received By: <br /> EHD 48-02-025 O `�C) ! <br /> REVISED 11!17/2003 SR FORM(Golden Rod) <br />