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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTH OWRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR _ <br /> 1 0 � b ^ t ] /; i f Q CHECK If BILLING ADDRESS <br /> FACILITY NAME I`T I`� (�I 1� <br /> SITEADDRESS <br /> 7l.�/ <br /> I 1 Street Number Direction Street Name City Zip 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 /> 400 646— oco00) 1U31409-5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 0011 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> F IL I T F l ` ' CHECK If BILLING ADDRESS <br /> BUSINESS NAME V P N E- <br /> T. <br /> `7 <br /> HOME or MAILING ADDRESS FAX# <br /> z S 3 S I►U I A- V J A M 9R- (20 L4- Lt-2. <br /> CITY 5Tco Ir lL--p N STATE 1/1�* ZIP 1752-05, <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 nd FEDERAL la s. <br /> APPLICANT'S SIGNATURE: DATE: 7i/ 2d l <br /> PROPERTY/BUSINESS OWNER OPERATOR I MA ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT' 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme ' n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provi �S� <br /> my representative. 4 <br /> e, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: i �'^e� �7�Q(�7� <br /> I'� C',f3 <br /> Y"� <br /> ACCEPTED BY: � t EMPLOYEE#: G ` DATE: 2 1 <br /> ASSIGNED TO: eh G EMPLOYEE#: QJ:1 / , t a DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: <br /> Fee Amount: L4 S�uf — Amount Paid (p.D� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />