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SAN JOAQUIN'-'OUN'I'Y ENVIIZONMENTAL HEALTI' "EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK <br />F-1BUSINESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />NAME �' <br />S• <br />PHONE# <br />r/1 o©� <br />c A VF o -\n.tCT, C. <br />S <br />OWNER /OPERATOR <br />HOME or MAILING ADDRESS <br />FAx # <br />CHECK If BILLING <br />l.�•�1.11.�.1Z AuFN�F <br />(S(.o� <br />q c <br />) 1�3 <br />ADDRESS <br />FACILITY NAME n <br />Payment Type <br />Invoice # <br />SITE ADDRESS 3 2 •Z <br />�^ <br />Street Number <br />Direction <br />Street Name <br />ity <br />Code <br />HwE or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY Y <br />STATE ZIP <br />PHONE #1 <br />( ) <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />^\ <br />CHECK <br />F-1BUSINESS <br />/1 % _ I <br />C , I • 4A4%- ( c, £ `` 1 <br />x-1-1 K <br />If BILLING ADDRESS <br />NAME �' <br />S• <br />PHONE# <br />EXT. <br />c A VF o -\n.tCT, C. <br />S <br />C) <br />HOME or MAILING ADDRESS <br />FAx # <br />SERVICE CODE: qg <br />l.�•�1.11.�.1Z AuFN�F <br />(S(.o� <br />q c <br />) 1�3 <br />CITY SjA E <br />ZIP <br />BILLING ACKNOWI,EDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTII 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 FEDERAL laws. <br />APPLICANT'S SIGNATURE:. <br />DATE: _ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT au Q (� <br />If APPLICANT is not the B11.1ING 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 HEALTFI 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: S I <br />PAYMENT __ <br />COMMENTS: <br />U HECEIVED <br />SEP 2 4 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SER!'ICES <br />ENVIROWAENTAL HEAL' <br />APPROVED BY: C <br />EMPLOYEE #:, 'ZZQ Z <br />CC11 <br />DATE: _ �� , 0 <br />ASSIGNED TO: 1) <br />EMPLOYEE #: 7 0 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: qg <br />P f E: Y. <br />Fee Amount: q <br />I <br />Amount Paid <br />Payment Date <br />`Received <br />Payment Type <br />Invoice # <br />Check # / 3 <br />By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />