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AWL <br /> SAN JOAQ , OUNTY ENVIRONMENTAL HEALT uPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l cJ <br /> OWNER/OPERATORJ6W <br /> rE, <br /> tt <br /> �--'���� �� DECK If BILLING ADDRESS El <br /> FACILITY NAME Loa( �i U y, <br /> SITE ADDRESS1 <br /> ree YIPO mbar ire tion Street Name i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,i T1SEF?V1 <br /> ES <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (7 )- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEj C PHONE# s r ' ' EXT. <br /> f <br /> HOME or MAILING ADDRESS FAX# <br /> CITY t STAT ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned$09perty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONM5,NTAL REALTH 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r ':5 <br /> PROPERTY/BUSINESS OWNER TOR)MANAGER ❑ OTHER AUTHORIZED AGENT❑ JJIL <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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />