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SAN JOAQ61N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type f Business or Property. FACILITY ID# SERVICE REQUEST# <br /> 6-0- <br /> OWNER/OPERATOR / <br /> a n CHECK If BILLING ADDRESS <br /> FACILITY NAME - V <br /> SITE ADDRESS1/N_ /t <br /> vt Vr <br /> Street Number Dlredlon Sh¢¢t Name city Zip Code <br /> HOME♦/orr MAILING ADDRESS (if <br /> 'Different from Site Address) u�/� _ <br /> o"`�",�' ri('/- Street Number 5treet Name <br /> ot <br /> CITY STAT <br /> 5VLk iP <br /> PHONE#1 EM' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /, n 1e., p / (� t�1 <br /> J C 1 QV, L / CHECK If BILLINGADDRESSICF <br /> BUSINESS NAME ' P ONE# _ U 2 ExT. <br /> HOME or MAILING ADDRESS ^ J J <br /> I FAX# <br /> CIN 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to bep ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: S ` I <br /> PROPERTY I BUSINESS OWNER MI OPERATOR I ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT I 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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOVl �tO me or <br /> my representative. Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> � f ) ^' M025 <br /> RT,k fN <br /> ACCEPTED BY: - A EMPLOYEE#: DATE: 7 <br /> `b--t> <br /> '�!� <br /> ASSIGNED TO: EMPLOYEE#: DATE: �, 'l - -/—)/ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: CEJ Amount Pai 39 �� Payment Date J��—/ <br /> Payment Type �� Invoice# Check# Receiv6d By/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />