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SAN JOAQUIIIUNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP RATOR <br /> Pt t)1C CHECK If BILLING ADDRESS <br /> FACILITY AME <br /> SITE ADDRESSDo <br /> 2 Street Number DI tion treat Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY S Cup AV $TATECA ZIP <br /> PHONE#1 EXT• LAND USE APPLICATION# <br /> 741ct3- <br /> (% ) �G�37b7 340--36 <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> TRACTO , / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME - PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> ' 6 ( ) 631- s 1 <br /> CITY V,b f UU STATE ZIP a ao <br /> BILLING 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 <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 FEnE laws. (� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER/5-- <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLicANT is not the Biaxg PAR71%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: S I j �.J [ r� PAYMENT <br /> COMMENTS: rlt- UE <br /> 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONM <br /> HEAENTqL <br /> LTH DEpARTMEN <br /> 7. <br /> ACCEPTED BY: EMPLOYEE M > - DATE: <br /> L 7 <br /> ASSIGNED TO: f !V EMPLOYEE M 7 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: I q G P i E:;13 L, , <br /> Fee Amount: 7 &? Amount Paid 'a (nj Payment Date `4 l` 0 <br /> Payment Type ✓ Invoice# Check# a 3 S (7 S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />