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SAN JOAQRCOUNTY ENVIRONMENTAL HEALT_ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WNER/OPERATOR -, <br /> r I•/`i_I^ — _��,1/,�'-• CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Z C7l S 1 V tA/.[ '7 _ A ham— � 1 p chh `� �Z°S <br /> Street Number Direction Street Name Cit 2i 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 /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ''�,'•J ) %- �' ! -- L�tL( �- � of <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> Z' ( ) <br /> CITY STATE 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 <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 FEDERAL laws. <br /> APPLICANT'S NATURE: -7�`=' ' L D� : rt <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG/ENT❑ <br /> IfAPPLiCANT 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 ENvIRONNIENTAL HEALTH DEPARTN[ENT 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: h--off f'1 <br /> COMMENTS: ` I �� J6fLZ6.v EIV <br /> sA <br /> JA N ,9 �y014(� <br /> FN AQU1jy <br /> L pF AEN NTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: I G <br /> I <br /> ASSIGNED TO: �r� EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: <br /> Fee Amount: Z y' Amount Paid /�S(fib Payment Date <br /> Payment Type Invoice# Check# Received By: '� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />