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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 I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 6 ?7 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# <br /> (;101/ ) 407 8173 <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> BUSINESS NAME PHONE# El . <br /> ti 7 Ar7? <br /> mom MAILING ADD ESS FAX# <br /> ( 1 <br /> CITY STATE ZIP <br /> B=G <br /> 1L N 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. 5 n <br /> eTPMAA T'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN A .R ❑ OTHER AUTHORIZED AGENT 13 <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 enviro ental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available 1,4w)ig,$ame time It is <br /> provided to me or my representative. R , I 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: O <br /> 1yeFT�RQFpQ"'lit 1N <br /> y4ARTNpry <br /> ACCEPTED BY: EMPLOYEE M DATE: /- <br /> ASSIGNED TO: EMPLOYEE#: DATE: !� <br /> Date Service Completed (if already completed): SERVICE CODE: O P 1 E: <br /> Fee Amount: 1 Amount Paid I Payment Date <br /> Payment Type Invoice# r , Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />