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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH bUYARI'MENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />ft <br />au dc <br />07 <br />OWNER / OPERATOR�Q777 <br />�� ; <br />I„ <br />v` <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />C.� u tC' <br />S <br />EMPLOYEE #: <br />SITE ADDRESS R <br />v dreet Number <br />DATE: <br />ASSIGNED TO: <br />f �L/ <br />/1Z I AI 1treet <br />tri <br />DATE: <br />Direction <br />SERVICE CODE: <br />Name <br />Cit <br />2i Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />�� g f_ O D <br />Payme <br />Date L I ( S p-7 <br />Payment Type <br />Invoice # <br />Street Number <br />Check # D 7 <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION <br />PHONE #2 EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PHONE#Elm <br />HOME or MAILING ADDRESS )) 1 <br />too -1 C Ld <br />FAX# <br />(,Zpq (r� / ZL� b <br />_ <br />CITY i CA-_- <br />STATECt',q zip C36 -7 -Lt D <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL. HEM,rii 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. <br />APPLICANT'S SIGNATURE: DATE: <br />—z <br />PROPERTY / 131 ISI NESS OWN FR ❑ OPERATOR /MANAGER ❑ OTI IER AIITIIORIZED AGENT M 044 4e 4ta".t.4G�lj� <br />/I*APPLWANT is not the BILLING P/IRTY. proof of aitthorization to sign is regWred 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 SANJOAQUIN COUN'rY ENVIRONMEN'l-AL. HEAI:I'li DEPARTMEN'r as soon as it is available a r the same time it is <br />provided to me or my representative. n�-OIF� <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />N <br />SO PCt,�,NGD �� <br />NMEN <br />eQPR'�M <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: Oi <br />LI <br />Amount Paid <br />�� g f_ O D <br />Payme <br />Date L I ( S p-7 <br />Payment Type <br />Invoice # <br />Check # D 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />