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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # EXT. <br />19� _ � � I <br />SERVICE REQUEST ## <br />FAX# <br />CITY C TDC TE ZIP 9S21 2- <br />ACCEPTED BY: <br />\-3-yy ! ES9,-2— <br />S►-/�i 0 <br />12OWNER <br />OWNER/ OPERATOR <br />CHECK BILLING El <br />// f> <br />If ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />a <br />/q) <br />d <br />Street Number <br />Direction <br />Street Name <br />Amount Pakp�s� v <br />cityZi <br />C <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />�FC <br />._> <br />C Street Number <br />Receiv d By: <br />Street Name <br />CITY <br />STATE ZIP 4PA) <br />STT r <br />PHONE #1 EXT <br />APN # <br />n(0 0-7�U2 d <br />Cy <br />LAND USE APPLICATION # J <br />y�NViR Qqltv <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE AR <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �/� C CHECK if BILLING ADDRESS <br />r ( r v I <br />BUSINESS NAME <br />PHONE # EXT. <br />19� _ � � I <br />HOME r MAILING ADDRESS <br />FAX# <br />CITY C TDC TE ZIP 9S21 2- <br />Vir <br />D <br />2018 <br />ouiv <br />T,q� <br />FENT <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledDe 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 />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 SIGNATURE: <br />�- — - - - ---- DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OT ER ORIZED AGENT ❑ <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 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 provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: ' V V <br />�j� <br />COMMENTS: ro /�/�WI 2r / /� / J v !i 0 <br />Q q -7 <br />� JCJ � �' C"iG 14 P1, <br />d14 rm <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: I/Iuf <br />7 <br />I x <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: LtI <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />d <br />P/ <br />C/ <br />Fee Amount: <br />Amount Pakp�s� v <br />Payment Dat <br />Payment Type <br />Invoice # <br />Check #01�1 <br />Receiv d By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />