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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/OPERATO CHECK if BILLING ADDRESS <br /> 19 <br /> 2 � <br /> FACILITY NAM <br /> /V �2 <br /> $tTE ADDRE �v�v Street Number a tlo Zest Code <br /> HOME or MAILING ADDRESS (if Dl1ferent from Site Address) <br /> Ow? CmiL ( Street Number Street Name <br /> CITY L�� $T/�TE ZIP 'g�-3 Z- <br /> PHO14- <br /> NE##11 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM j� PHONE# EXT. <br /> �u .2 L�� oq /la Zz13 <br /> HOME opl' ADDRESS / FAx# <br /> 1 DS rD al ac- � ( ) <br /> CITY r/ — STATE �A 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 1 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 <br /> �Uf,C wo <br /> APPLICANT'S SIGNATURE: w DATE: <br /> PROPERTY/BusINESS OWNERS OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: O <br /> h eNVRCQUtN CC ?1 <br /> E9CTH��p FNT�>), <br /> ACCEPTED BY: �/)P�� EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: V Q'/ EMPLOYEE#: DATE: 11Z <br /> Date Service Completed (ifalready completed): SERVICE CODE: d(p P I E: -70 Z <br /> Fee Amount: `O�. Amount Paid Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />