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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />0j, qlaa <br />FACILITY ID # <br />SERVICE REQUEST # <br />R e sravran,T <br />�_9 l�/� <br />Y <br />PHONE# EXT• <br />310 ami s s -77 Z <br />FAX # <br />Ca - <br />U -4-Ca- <br />f7 <br />Lzyq <br />t ) <br />CITY m <br />OWNER/ <br />OWNER /OPERATOR <br />(Z o 7-C� S%1 <br />Pa t-hq K <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME vr8 eiri m <br />C <br />✓- <br />EMPLOYEE #: �'` <br />SITE ADDRESErlOr a <br />ASSIGNED TO: ,At j <br />MOYaa�O� <br />SCVck--ton <br />DATE:/i�1 / <br />Date Service Completed (if already completed): <br />10�7 <br />SERVICE CODE: ? <br />P / E: <br />eeAmount: , �t� <br />[F=tType <br />Amount Paid1 . <br />Payment Date <br />Street Number <br />Direction <br />Street Name <br />Check # D D g <br />CI <br />21 Code <br />HOME or MAILING ADDRESS (if Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />t ) <br />09 2- 0070 - 00 <br />PHONE #2 EXT. <br />t ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />0j, qlaa <br />cw* A <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME:� <br />L't] <br />�_9 l�/� <br />Y <br />PHONE# EXT• <br />310 ami s s -77 Z <br />FAX # <br />HOME Of FAILING ADDRESS _ <br />f7 <br />Lzyq <br />t ) <br />CITY m <br />STATE ZIP l 4 <br />O <br />ACCEPTED BY: I fa �� <br />W� l'� <br />C <br />✓- <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this appl' i n and at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST nd FEO RAL laws. f 7 <br />APPLICANT'S SIGNATURE: DATE: �/ �-/ f 2-0 11 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER' OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BiLLiNGPARTI , proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />0j, qlaa <br />cw* A <br />COMMENTS: <br />(P� <br />�v(-./V�h <br />sANF1-02720, <br />0gQU/N <br />EN <br />HFAC HR�NMN �N1Y <br />ACCEPTED BY: I fa �� <br />W� l'� <br />C <br />✓- <br />EMPLOYEE #: �'` <br />DATE: T E'�%� <br />ASSIGNED TO: ,At j <br />, <br />EMPLOYEE #: <br />DATE:/i�1 / <br />Date Service Completed (if already completed): <br />SERVICE CODE: ? <br />P / E: <br />eeAmount: , �t� <br />[F=tType <br />Amount Paid1 . <br />Payment Date <br />Invoice # <br />Check # D D g <br />Received By: L6 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />