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SAN JOAQ&OUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Service <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />ccL C k3 ► <br />SERVICE REQUEST # <br />5M (q I) -I <br />OWNER/+PERAT <br />11 r 6 / r / <br />�� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME a/2 A 4 —n - <br />(! (vf ( <br />CITY ""`L x <br />STATE ZIP / �ZSj <br />SITE ADDRESS ZJ� <br />Number <br />Direction <br />u %� t�l� <br />�treet <br />`J <br />Name <br />TDStreet Ci <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CIN <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />( Z 3 oz v 1-Z. <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUES OR <br />/-h lenii ll el s ka. t,,) <br />CHECK if BILLING ADDRESS <br />BUSINE$',� NAME/ / /JA / JQ <br />i �r <br />PH NE EXT. <br />$/ <br />HOME or MAI /4DPRE S <br />�� ((fit lti a /� f <br />FAX # <br />(1z� `46 ZS-Z- <br />CITY ""`L x <br />STATE ZIP / �ZSj <br />i <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 />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. /` % �CX <br />APPLICANT'S SIGNATURE: �— DATE:35 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <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 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. <br />TYPE OF SERVICE REQUESTED: W7 l U <br />�VV Et <br />A,qY <br />COMMENTS: <br />T <br />M,4 CF�LFO <br />N �i Qtr <br />R H <br />co <br />ti* <br />��'hy, <br />6y� <br />ACCEPTED BY: ! T 1 q Jy <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />1 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: !1 <br />PIE: 23 J <br />Fee Amount: I) QJ <br />Amount Pai <br />37S- DD <br />Payment Date <br />/Z <br />Payment Type <br />Invoice # <br />Check #3 <br />Red ived By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />