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SAN JOAQUUICOUNTY ENVIRONMENTAL HEALTH RPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> J� r n CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS / l/Vl` } <br /> ( // (,A1 C ity 5 <br /> Z Street Number Direction O "� Street Name ��" Ci — ` � Zi Code <br /> HOME or MAILING ADDRES (If\rnlfferent from SJ ` <br /> Site Address) <br /> l �"/tV, V t 1 Y Street Number Street Name <br /> CITY f L� ( 6 \ STATE ZIP L ,y <br /> \t J L U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20ct) 8q1 ( b�7Z <br /> PHONE#2 EXT. BOS DISTRICT -][LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` '' �, / ��Q/� <br /> S <br /> fff CHECK If BILLING ADDRES <br /> BUSINESS NAME 11`G, \ (� PHO # EXT. <br /> HOME or MAI ING ADDREiSS `f / \ i� FACX# <br /> q w U M � c ) <br /> CITY6-�0(" ^ STATE � ZIP C z ( 11 <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 /> I also certify that I have prepared this application and that the work to be performed will b:DATE:-in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT nd FED E AL I'ws. <br /> APPLICANT'S SIGNATURE: w — w <br /> PROPERTY/BUSINESS OWNER® OPERATOR/ ANAGER ❑ OTHEA HORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY,proof of authoriza o o sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, a 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 in tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is providggi�' <br /> my representative. //++/i�f,�` �aN�' <br /> TYPE OF SERVICE REQUESTED: �(�� �`� <br /> COMMENTS: QNdp �,J' <br /> QqLtlll! <br /> MEq�rH of 011111 <br /> FJ►T <br /> ACCEPTED BY: �it EMPLOYEE#: ` DATE: <br /> ASSIGNED TO: U EMPLOYEE#: G 73 <br /> DATE: ? l f— <br /> Date Service Completed (if already completed): SERVICE CODE'gCo 6 r P 1 E: 0 <br /> Fee Amount: ?,. Amount Paid l Payment Date <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />