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SAN JOAQUIN `'OUNTY ENVIRONMENTAL HEALTV T)EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: <br />FACILITY ID # <br />SERVICE REQUEST # <br />(R1'� <br />x'51 fLAI <br />OWNER / OPERATOR <br />SAN JOAQUIN COUNTY <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />A <br />ACCEPTED BY: <br />SITE ADDRESS qW <br />DATE: 7/ p ( C> <br />IC.1 <br />c �d cant) <br />WWI <br />T52 O <br />11 Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />a0141 <br />Payment <br />Street Number <br />Street Name <br />CITY <br />Check #,5 -lo -2-7 <br />STATE ZIP <br />PAk <br />LW ENLILAN-QYN <br />PH E #1 <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />(M) 3 <br />O L/7- 4+2-0 --0 <br />-s - <br />PHONE #2 <br />EXT. <br />DISTRICT <br />166 <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR llm CSU CHECK If BILLING ADDRESS <br />ED <br />BUSINESS NAME PHONEI —j T' <br />0 ( , <br />HOME or MAILING ADDRES _ FAX # <br />( �) 40 C® <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. <br />APPLICANT'S SIGNATURE: 41-)m DATE: l <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT Qxbx'y � j 1 <br />� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required �_"""I 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 />%� <br />TYPE OF SERVICE RE QUESTED: C.(_5� J�l/l��—�(MENT <br />COMMENTS: <br />RECEIVED <br />MAR 19 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: O 3 2-4 <br />DATE: 7/ p ( C> <br />ASSIGNED TO: �-1 <br />( EMPLOYEE #: [• ZZ_ <br />DATE: 3 � Q / O <br />Date Service Completed (if already completed): <br />SERVICE CODE: Z <br />[Date <br />P / E:�� <br />Fee Amount: 3 [��'� <br />Amount Paid 2 <br />v <br />Payment <br />I O <br />Payment Type <br />Invoice # <br />Check #,5 -lo -2-7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />