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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />e FACILITY ID # <br />PHONE # EXT. <br />SERVICE REQUEST # <br />C Le o n \ n ci <br />bvtsI In el, <br />Date Service Completed (if already completed): � <br />Ga 00�'O�Z L43 <br />OWNER /OPERATOR <br />�( <br />.� i <br />Amount Pai � U� <br />CHECK If BILLING ADDRESS <br />Payment Type <br />_ <br />f, <br />iiiL <br />Re eived By: <br />FACILITY NAME <br />„ Mou� <br />SITE ADDRESS i (�Cr,_ <br />l <br />�T�1/i 5 tz)'-' Lo n <br />L 0 —1 `, <br />Street Number <br />Direction <br />Street Name <br />city <br />Zi Code <br />HOME Or MAILING ADDRESS <br />(If Different from Site Address) <br />.�//1 <br />Street NumberJ?o <br />O Street llq <br />CITY <br />STATE rpv ZIP %� <br />P NE # , <br />Q� EXT, <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ml <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS E] <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 b performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT ❑ <br />I{APPLICANT is not the BILLING PARTY, proof o authorization to sign is required Tilie <br />AUTHORIZATION TO RELEASE INFORMATION: When pplicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided to me Or <br />my representative. 0 <br />E I TYPE OF SERVICE REQUESTED: C C f S C U1-\ V" It"A iii, <br />COMMENTS: <br />c <br />1 U I(j) �—�- ?) -�� C <br />0 <br />?Iz D 5 4- L- &5 > <br />-r <br />sgN✓o 02 ? <br />h(Tyo NMN <br />FAgRr.Tq< <br />ACCEPTED BY: try nh c <br />EMPLOYEE#: <br />DATE: �JZ /'t'—'l T <br />ASSIGNED TO: -,�mn <br />EMPLOYEE #: " <br />DATE: �— / 2-119 <br />Date Service Completed (if already completed): � <br />SERVICE CODE: b (� <br />PIE: w(U Z <br />Fee Amount: I5�19- D';5 <br />Amount Pai � U� <br />Payment Date 7 -211 <br />Payment Type <br />Invoice # <br />Check # ?--17_2_2_1, <br />Re eived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />