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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 /> 'ti�Y.JC U ` t O S e \rzos/A S CHECK If BILLING ADDRESS <br /> FACILITY NAME �/� <br /> SITE ADDRESS -11203J ��/� t \ �� C --",,2,k <br /> Street Number Direction Street Name} citya_ 1/Zi -Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2Oo C) e� Vl 1 <br /> Street Number Street Name <br /> CITY l n _ STATE CA ZIP <br /> PHONE#1 1 r� EXT. APN# LAND USE APPLICATION# _ 1 <br /> (11) 3Q2- 5011`5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME `'� OC �^ �^� PHONE# ���� 1 <br /> HOME Or MAILING ADDRESS l t 1 FAX# l <br /> 2 0 CA • ( ) <br /> CITY ot STATE ZIP Ll <br /> BILLING ACKNOWLE GEMENT: 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 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 /> APPLICANT'S SIGNATURE:.\( Moi S 6 ( � Q S O"S DATE: 1 I <br /> PROPERTY/BUSINESS OWNExsot <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT the BILLING PARTY,proof of authorization to sign is required Tifle <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���in'''f��-ormation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provwfN- P <br /> me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C)COMMENTS: c,,o2j� <br /> H r/y2Q, <br /> FFu <br /> �Rr�Fkt <br /> ACCEPTED BY: hl�f�/\ }/ 0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: ` 6 n/ r ( M o n EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0149PIE: } <br /> Fee Amount: , Amount Paid � � Payment Date <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />