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SAN JO.AQUI 7UNTY ENVIRONMENTAL HEALT' EPARTMENT <br />SERVICE REQUEST <br />Typef Business or Property <br />Ci (J LJJ <br />G(S T— £ F t T <br />FACILITY ID # <br />2s l <br />SERVICE REQUEST # <br />`J1200 <br />`� <br />PHONE # <br />(2,61 <br />EXT. <br />401-43. <br />HOME Or MAILING ADDRESS %1 r- <br />/CtI <br />lA D 17 �1 <br />OWNER /OPERATOR <br />411 / &3+-2 <br />CHECK BILLING <br />STATE 019t <br />ZIP V-1 2i'� <br />if ADDRESS <br />FACILITY NAME stl L t <br />nv <br />EMPLOYEE #: <br />03-24 <br />/ <br />SITE ADDRESS <br />76/ <br />,� <br />C• <br />'tel � <br />% 1 <br />Cr <br />/ �Zi <br />Street Number <br />Direction <br />l/► S eet a <br />itG' <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Payment TypeLZ <br />Invoice # <br />I <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #T EXT. <br />( ) <br />BOS DISTRICT <br />/ <br />LOCATIpN CODE <br />/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� <br />1 <br />G(S T— £ F t T <br />CHECK if BILLING ADDRESS <br />BUSINESS E ` n/j I I Vi <br />l 1 <br />PHONE # <br />(2,61 <br />EXT. <br />401-43. <br />HOME Or MAILING ADDRESS %1 r- <br />/CtI <br />.JUN - 9 2010 <br />(�) <br />411 / &3+-2 <br />CITY <br />STATE 019t <br />ZIP V-1 2i'� <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 ap ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDERAL 1 <br />APPLICANT'S SIGNATURE: Y// Z� (h DATE: (�C (C% 0 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN 7CC it <br />If APPLICANT is not the BILLING PARTY, proof of authorization to si-n is required <br />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 />TYPE OF SERVICE REQUESTED: <br />G(S T— £ F t T <br />NT <br />COMMENTS: <br />RECEIV <br />.JUN - 9 2010 <br />SAN JOAQUIN COUNTY <br />HATH DEPARTMENT <br />ACCEPTED BY: L� v t <br />EMPLOYEE #: <br />03-24 <br />/ <br />DATE: <br />w� <br />/ C'I <br />ASSIGNED TO: O . 1 (,C <br />V <br />ralready <br />EMPLOYEE #: I' 3 /`—'"] <br />r <br />DATE: q � L) <br />Date Service Completed (if coompleted): <br />SERVICE CODE: <br />P/ E: -2,kp <br />Fee Amount: -3 S Qi) <br />Amount Paid 3 (� S D d <br />I <br />Payment Date Iq '0 <br />Payment TypeLZ <br />Invoice # <br />I <br />Check # Sa I l? <br />Received By: <br />I <br />EHD 48-02-025 SIR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />