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SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BIL N2 ADDRESS <br />BUSINkss NAME <br />I' SERVICE REQUEST # <br />HOME or MAiuNG ADDRESS <br />OWNER/ OPERATOR <br />CHECK If BILLING Aopgass <br />Wwal ' PTTI <br />SITE ADDRESS <br />Str"t Nuinbor <br />HOME or MAILING ADDRESS (if n rent from Ske Address) <br />a CYS S. 10 0 <br />Street NUM <br />Ci <br />STATE zip <br />2-- <br />I. <br />10 <br />LICATION # <br />CONTRACTOR / SERVICE REQUESTOA <br />REQUESTOR <br />CHECK If BIL N2 ADDRESS <br />BUSINkss NAME <br />HOME or MAiuNG ADDRESS <br />BILLING AC1N1M1E_1GEMENT: 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 />CouNw Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:f DATE: <br />PROPERTY / Busmm OWNERIJ oPERAToR / mANAGER 13 OTmR AuTnoRizED AGENTO:;7-�>6-m V-k-c� a, <br />IfAPPL1CANTisnottheBILL)NGPAR proof of authorization to sign is required Title <br />AUTHORIZATION LO REI&ASE INEQRMATION: When applicable, 1, 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 enviromnental/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 />nrovided to me or mv revresentative. <br />TYPE OF SERVICE RmuESTED: <br />COMMENTS: <br />2 8 <br />aw- <br />'T <br />HEALTH <br />FERMIT[USERVICES <br />EMPLOYEE #: <br />ACCEPTED BY: L <br />ASSIGNED TO: A C A'7,9 I <br />Date Service Completed (ff already completed): <br />Amount Paid Payment Date <br />Payment Type Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />