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SAN JOAQUIN I-vUNTY ENVIRONMENTAL IIEALTH DE...RTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME , <br />SERVICE REQUEST # <br />PHONE # Ex,. <br />HOME Or MAILING ADDRESSFAX <br />Poe�x 3�3Zs <br />ACCEPTED BY:A%q <br /># <br />(26Y) U4 �8 <br />OWNER / OPERATOR <br />-� IN x <br />CHECK if BILLING ADDRESS <br />FACILITY NAME QtA i.A 1 J+ <br />SITE ADDRESS <br />DATE: <br />mit„1� ��, f ,� <br />SERVICE CODE: <br />9s Z'D <br />Street Number <br />Direction <br />Street Name <br />O <br />City <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Invoice # t d? -7-7 <br />4L491., I Cc.�IY10> 0 ' Street Number <br />Stre t Name <br />CITYSTATE <br />EI- IVN <br />ZIP <br />.;_4.. �ctzy <br />PHONE #1EXT <br />APN <br />'lS <br />LAND USE APPLICATION # <br />($41 ) $3� tOL�lt�b-0 <br />0 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT// <br />4- <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR _ <br />L,(��i � � � �,� ^ I �_� �n r47 C �•, � <br />' ` ` (r v C! �\-JLJ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME , <br />COMMENTS: <br />PHONE # Ex,. <br />HOME Or MAILING ADDRESSFAX <br />Poe�x 3�3Zs <br />ACCEPTED BY:A%q <br /># <br />(26Y) U4 �8 <br />!i <br />CITY 's-noLKTU/V <br />STATE C-} ZIP 9S-2-13 <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 zhar;es 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. <br />APPLICANT'S SIGNATURE: Lr--� _ 4�DATE: //- Z I - 0 7 <br />PROPER rY/BI'SINESSOWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT�C -�N � r2AkC-T-C'C <br />1f,1 PP0C.IA'T is mol the BILLIAG PART1, proof ojauthorization 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 />inform ition to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAi,TH DEPARTMENTaS soon as it is available and at the same time it is <br />provided to me or my representative. neNT <br />TYPE OF SERVICE REQUESTED: <br />PAY IE�vEo <br />COMMENTS: <br />QutN COUtAV <br />SNATN DEPARTMENT <br />ACCEPTED BY:A%q <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />O <br />Payment Date <br />Payment Type I S <br />Invoice # t d? -7-7 <br />Check # S Cf <br />Received By: <br />EHD 48-02-025 ���`{ J !/ • V SR FORM (Golden RodQU <br />REVISED 11/17/2003 r <br />