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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ %— RECEIVEu <br />FACILITY ID # <br />BUSINESS NAME <br />L\VNVC . <br />SERVICE REQUEST # <br />PHONE# <br />(orl) <br />EXT. <br />yb -b3 <br />HOME or MAILING ADDRESS _ 1 <br />'� —' <br />FAX # <br />OWNER/ OPERATOR , <br />STATE (1 r, <br />"`— 0 <br />ZIP C')"--2 <br />CHECK <br />� <br />1A <br />c:c- )00 c C."t' e c - <br />If BILLING ADDRESS <br />FACILITY NAME <br />, <br />Invoice # <br />SITE ADDRESS �0 h yC <br />Check # ?-531 <br />alb "'C-C_ <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />(✓ Ct) CS <br />PHONE #Z EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/ %— RECEIVEu <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />L\VNVC . <br />ACCEPTED BY: D l ud <br />' T <br />PHONE# <br />(orl) <br />EXT. <br />yb -b3 <br />HOME or MAILING ADDRESS _ 1 <br />ASSIGNED TO: L <br />FAX # <br />EMPLOYEE #: 3S S-6 <br />CITY 14) �-o C <br />STATE (1 r, <br />"`— 0 <br />ZIP C')"--2 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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: DATE: 1 U L. <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT W <br />If APPLICAN \ is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO REL ASE 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. pAYMEN"f <br />TYPE OF SERVICE REQUESTED:F <br />/ %— RECEIVEu <br />COMMENTS: <br />JUN 10 2004 <br />SAN JOAC IUM COUNTY <br />ENM.RON.MEENTA1.. <br />HEALTH aEFOUMW <br />ACCEPTED BY: D l ud <br />' T <br />EMPLOYEE #: C: j 2 / <br />DATE: �Lj <br />ASSIGNED TO: L <br />EMPLOYEE #: 3S S-6 <br />DATE: 0(0 G1 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ) 9 R" <br />P / E: Z3. ctir <br />Fee Amount: 27 S c- L <br />Amount PaidlC-D <br />cl)Payment <br />Payment Date <br />Type <br />Invoice # <br />Check # ?-531 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />