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SAN JOAQUfRCOUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU�EEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 60 <br /> A".iStreet Number Direction Street Name C ItyZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSO <br /> BUSINESS NAME 1 �' PHONE# EXT. <br /> �> n tet^ L I c • ' <br /> HOME or MAILING ADDRESS �� ttr FAX# ` J <br /> CITY /S STATE cl�l /I ,p ZIP <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 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: DATE: <br /> 1:1t <br /> PROPERTY/BUSINESS OWNER OPERATOR/ ER ❑ OTHER AUTHORIZED AGENT ISI u z( ;, t: 'G <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 propertyted at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site nt information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same ti to me or <br /> my representative. ������ �Ir <br /> TYPE OF SERVICE REQUESTED: � <br /> COMMENTS: F ✓OA <br /> 20� <br /> ti M•,o�MFN0, 8 <br /> gRT��N ry <br /> ACCEPTED BY: t k C � /q EMPLOYEE#: : I, DATE: lj _ <br /> ASSIGNED TO: y a, EMPLOYEE#: DATE: <br /> 11 <br /> Date Service Completed (if already Completed): SERVICE CODE: l J� P'/E: <br /> Fee Amount: q I <br /> Amount Paid q/? Payment Date "r <br /> Payment Type /7 t) Invoice# CTheck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />