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SAN JOAQUU OUNTY ENVIRONMENTAL HEALD EPARTMEN FILE <br />`.� <br />SERVICE REQUEST 1 <br />Type of Business or Property <br />� <br />FACILITY ID # <br />BUSINESS NAMEFi 1 <br />SERVICE REQUEST # <br />I <br />drAn- <br />PHONE# %� Ext. <br />( ) h <br />h•t��D���� <br />F <br />2- <br />5e2��3�(a� <br />Yl , <br />CITY <br />( <br />v <br />STATE ZIP COW5 <br />Fee Amount: 315 <br />OWNER/ OPERATOR <br />�/� i <br />CHECK if BILLING ADDRESS 13 <br />Payment Type <br />Invoice # <br />FACILITY NAME r. <br />Received By: <br />SITE ADDRESS 4161 J <br />Lfl-g <br />Street Number <br />Street Name <br />cityZi <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />/ <br />PHONE #1 <br />EXT <br />APN # 'n 9 -j <br />LAND USE APPLICATION # <br />PHONE#2 <br />Exr. <br />BOS DISTRICT j� <br />rLqC,1AT1ON CODE <br />t <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />.i <br />� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEFi 1 <br />�Q' <br />1 11 1 1 <br />SAN JOAQUIN COUNTY <br />EMPLOYEE #: HEAL EPDFPq I; ( /J,— <br />PHONE# %� Ext. <br />( ) h <br />HOME Or MAILING ADDRESSFAX# <br />2- <br />DATE: <br />( ) <br />CITY <br />( <br />v <br />STATE ZIP COW5 <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: —� l 1�IN� DATE: i " \� <br />PROPERTY/ BUSINESS OWNER 11OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 1E' <br />If APPLICANT is not the BILLING 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 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 />COMMENTS: <br />PAYMENT <br />RECEIVED <br />t <br />JAN 311 2014 <br />ACCEPTED BY: J_ (� �l.(( �n <br />lJ <br />SAN JOAQUIN COUNTY <br />EMPLOYEE #: HEAL EPDFPq I; ( /J,— <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1 Lt <br />P 1 E: Z -5;10 ? <br />Fee Amount: 315 <br />Amount Paid <br />�/� i <br />Payment Date G v/ �/ L� <br />Payment Type <br />Invoice # <br />Check # 5v <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />