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0 SERVICE REQUEST 0 <br />Type of Bus' ss or erty <br />BUSINESS NAME f/ !e. <br />P # ! % E?. <br />FACILITY ID # <br />(1-2 <br />SERVICE REQUEST # <br />3"'Mi <br />CITY } STATE ZIP <br />� coo <br />( (� <br />i ! <br />OWNER / 00RATOR <br />I jllrl� <br />all J <br />'Y`I <br />C'011T4etom- <br />CHECK If BILLING ADDRESS <br />FACILITY GAME / <br />u � <br />SI4tN l,A,,IN <br />TM <br />SITE ADDRESS <br />HSL }t'Dr <br />'-{ (� <br />Street Num/belt/ <br />D rection St <br />N e <br />Ci Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed <br />Street Number <br />Street Name <br />CITY <br />Fee Amount: <br />_ <br />STATE ZIP <br />PHHONNEJt1 <br />EXT. APN # <br />Date <br />LAND USE APPLICATION #1 <br />Invoice # Check # 1 } L, to <br />Received By: ( C' <br />PHONE#Z <br />EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUESTORI <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME f/ !e. <br />P # ! % E?. <br />HOME Or MAILING AD RESS <br />(1-2 <br />le <br />T f4 <br />CITY } STATE ZIP <br />FILLING ACKNO DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specs ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my busines as identified on this form. <br />I also certify that I have prepared this a licati nand that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, .standards, TATEd 1"EDERAL 1 <br />APPLICANT'S SIGNATURE: , 79x/& DATE: <br />PROPERTY/ BUSINESS OWNER ❑ 'OPERATOR / NIANAGER ❑ OTHER AUTHORIZED <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 <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. <br />_ n r•- n t�C' <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />'Y`I <br />C'011T4etom- <br />SI4tN l,A,,IN <br />TM <br />HSL }t'Dr <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />t`3� <br />Amount Paid <br />� � , � <br />Paymen <br />Date <br />Payment Type I _--- <br />Invoice # Check # 1 } L, to <br />Received By: ( C' <br />EHD 48-02-025 -SR FORIM (Golden Rod) <br />REVISED 11/17/2403 <br />