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IV SAN JOAQU°--`COUNTY ENVIRONMENTAL HEAL''--�DEPARTMENT <br />SERVICE"REQ'UEST <br />Type of Business or Property <br />BusIN>=ss NAMEZz% -�� .: <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />OWNER OPERATOR <br />ASSIGNED TO: � <br />CHECK If BILLING ADDRESS <br />FACILITY DAME <br />DATE: g —0S� <br />Date Service Completed (if already completed): <br />SITE ADDRESS 6 /D / 9-jQt'J�� <br />Street Number Direction <br />Street Name <br />9 �Q <br />Ci Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Payment Type ✓ Invoice # <br />STATE ZIP <br />PHONE#1 ' ExT <br />fZO� 33 —ivy z 3 ` <br />Received By: <br />APN# <br />oo -7 - 2—o-- / 7 <br />LANPLI ATI N# <br />I /r.JJ0 <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />REQUESTOR Je `c CHECK if B ILLING ADDRESS ❑ <br />ko�- <br />BusIN>=ss NAMEZz% -�� .: <br />PHONE #' <br />5 z3 <br />HOME or MAILING ADDRESS <br />FAX <br />, �� r <br />COYO STATE C ZIP V <br />W <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 ENVRONMENTAL 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: -Z —4 S <br />PROPERTY I BUSINESS OWNER ❑ PERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPLIc,4NT is not the BmgxgPARTY, 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 COLiNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is va' able and at the same time it is <br />provided to me or my representative.ENT <br />TYPE OF SERVICE REQUESTED: r�l�l�S��.4 '�'-.��RECEIV <br />C MENTS: <br />Y d s .r7 SAN J AQUIN C <br />76c-/ EALTH DEPARTMENT <br />ACCEP ED BY: C <br />EMPLOYEE M l �] <br />DATE: 0 <br />ASSIGNED TO: � <br />EMPLOYEE #: �v? �O <br />DATE: g —0S� <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 �� <br />P 1 E: 2'&0 <br />Fee Amount: <br />Amount Paid 1i D <br />Payment Date <br />Payment Type ✓ Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 74/17/2003 <br />