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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# EXT. <br />aell 4 -3,91 <br />FACILITY ID # <br />FAX # <br />SERVICE REQUEST # <br />C: a G -l- G v- c c .e r X <br />CITY <br />s <br />S T—• c /C 7--�, STATE C+'4 ZIP <? 5-� 0,5 - <br />�Z <br />cvQO 2 5-1 2 <br />5 k00 t/% 905 <br />OWNER /OPERATOR <br />M v-, S W dwori C % a <br />f1 <br />!� h h �/� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: --25DATE: <br />SITE ADDRESS '20 I G 6, y- <br />t% eLfS <br />O 7 .cam '?- o 4 <br />Street Number Direction <br />Street Name <br />City Zia Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Amount Paid a�s_ j -D <br />I <br />F <br />43 9( LD <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT.APN <br /># <br />LAND USE APPLICATION # <br />(IN) yiP°7—C>-?,oS' <br />PHONE #2 EXT. <br />(go,i) 993-I;L !6'c,?i6 <br />BOS DISTRICT <br />F�!� <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />r— /, / 7— Lc%� � s' CHECK if BILLING ADDRESS <br />BILLING <br />BUSINESS NAME <br />PHONE# EXT. <br />aell 4 -3,91 <br />HOME or MAILING ADDRESS - <br />FAX # <br />,1536- (l%i ry aA3 -P <br />026.7 q&12- <br />ZCITY <br />CITY <br />s <br />S T—• c /C 7--�, STATE C+'4 ZIP <? 5-� 0,5 - <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 F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: D 3- 2/- O <br />PROPERTY/ BUSINESS OWNER ❑ ;' OPERATOR / NIANAG1�RiL1 OTHER AUTHORIZED AGENT, -s 2 /e S rI » 9 s <br />s <br />If APPLICANT is n1p0heBILLING PAR TY 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 />TYPE OF SERVICE REQUESTED: <br />(� / �. <br />e o I< S /,N S e C' o NGl Q Y` <br />`1M e'Y-CN e . <br />COMMENTS: <br />1 N c e c� �Q <br />�5 ; A, <br />�cz t a y- <br />sT�c� I(P �� �i��- y, e v. o u fc !)/ 5%`a <br />�1 %�P 5 c, I�r <br />( <br />ACCEPTED BY: <br />�Z <br />EMPLOYEE #: J4 <br />DATE: 2 <br />ASSIGNED TO: J <br />/ <br />EMPLOYEE #: --25DATE: <br />Date Service Complto (if already completed): <br />SERVICE CODE: <br />P I E: 7-30 <br />HCl 7 <br />Fee Amount: •Z 5 <br />Amount Paid a�s_ j -D <br />I <br />I Payment Date <br />43 9( LD <br />Payment Type ✓ <br />Invoice # <br />Check # l I i p?i <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />