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SAN JOAQUINOUNTY ENVIRONMENTAL HEAL'I*EI'AR'I'MENT <br /> r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR� <br /> (�1 CHECK If BILLING ADDRESS <br /> 1% <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name CRY Zip Code <br /> HOME <br /> 01,�MAILING DDRESS (If Different from Site Address) <br /> 1 1 1 CL'C- Street Number Street Name <br /> CITY e STZIP I �1 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20) ql!s� Ir <br /> PHSE#2 EXT. BOS DISTRICT--71 LOCATION CODE <br /> c ) '7 _6 .7 3 1 .2_ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 7r+. CHECK If BILLING ADDRESS M <br /> BUSINESS NAME r PHONE# EXT. <br /> e-i ) — <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE Cc ZIP C `�. 0 S <br /> BILIANG 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 nic 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. 1 <br /> APPLICANT'S SIGNATURE: S _ DATE: I j�7 —02— <br /> ]PROPERTY <br /> 02— <br /> PROPERTY/BUSINESS OWNER❑i OPERATOR/MANAGER ❑ OTHER AUTIIORI"LED AGENT '�Q r�t C <br /> If APPLICANT is to 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: j <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH,SERVICES <br /> APPROVED BY: EMPLOYEE#: ATE: r <br /> ASSIGNED TO: EMPLOYEE#: L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: FP1 :�3 6 <br /> Fee Amount: Amount Paid Payment Date/� <br /> Payment Type ✓ Invoice it Check# 41� Received By: <br /> EHD 48.01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />