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SAN JOAQUI 'OUNTY ENVIRONMENTAL HEAL*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# EXT. <br />SERVICE REQQUUEST # <br />C A S X04 I( 0 <br />3 4P, <br />©(✓-�v � <br />J -! <br />OWNER / OPERATOR A n <br />1 8R /I 9AM C !� (1S <br />CHECK If BILLING ADDRESS <br />FACILITY NAME \ ALLL/�� 5459vlP6 Sf*1 %!OAI <br />v <br />SITE ADDRESS <br />EMPLOYEE #: C�'C-9" <br />E,457- HAjQbJA/(� WA ( <br />Date Service Completed (if already completed): <br />i5COCK c ON <br />Y5201f <br />6 Street Number <br />Direction <br />Street Name <br />Amount Paid <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />✓ <br />Invoice # <br />J 3 N & A-Vt . 4 7T Street Number <br />Check # H42 <br />Street Name <br />CITY` 1 0C16—00 � <br />$TATE C� ZIP <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />c2o9) x{66—�SI� <br />13' ©/ <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICTLOCATIO <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />CITY STATE ZIP <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 be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ZAPPLICANT'S SIGNATURE: '144DATE:7 <br />PROPERTY/ BUSINESS OWNER OPERATOR / MA GER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />ALJTHORIZATION 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. "-F Gp tJ'C �� _"� U '-) <br />TYPE OF SERVICE REQUESTED: v� z� <br />PAYM <br />COMMENTS: <br />'cutIVEID <br />APR 2 8 2009 <br />SMNVIROUICOUNTY <br />AL <br />HEALTH DEPARTME=NT <br />ACCEPTED BY: <br />©(✓-�v � <br />EMPLOYEE#: V 3 Z <br />DATE: L� (c) <br />ASSIGNED TO: <br />EMPLOYEE #: C�'C-9" <br />DATE: <br />I <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: z 3 ( <br />Fee Amount: 4 <br />Amount Paid <br />D <br />Payment Date y 1 Z v e� <br />Payment Type <br />✓ <br />Invoice # <br />Check # H42 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />