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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> q � Ll] ^ QS <br /> FACILITY NAME / / <br /> o Lei,Z C l l <br /> SITE ADDRESS uj 0- ,-t\r P <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,[ <br /> Sv 1 Street Number t C9 et Name <br /> CITY STATE ZIP <br /> PHONE#'I ` ExT. APN# LAND USE APPLICATION# <br /> (td'Y ) L/(�-8 - 'm <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or or MAILING ADDRESS FAX# <br /> CITY rr STATE ZIP <br /> ILLING 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. il <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: l/ DATE: <br /> T <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q <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: Ec315<CM77D 12,v Cir <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: (��3� DATE: <br /> ASSIGNED TO: EMPLOYEE#: SCc� DATE: A <br /> v.: <br /> ate Service C pletedif already completed): SERVICE CODE:SG �'Z� PIE: c fi U <br /> Fee Amount: Amount Paid IO L Payment Date <br /> Payment Type Invoice# Check# Received By: <br />