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SAN JOAQUIN'I:OUNTY ENVIRONMENTAL HEALTH IIEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />1,1"�j"y <br />4JQ-- <br />gWoo <br />(A/ <br />Ur 5 ; ZtJS ,1- ACtil" VZ> <br />T2eWtA ►ice . <br />6.6 <br />OWNER / OPERATOR <br />' <br />P i E:... <br />CITY / k1 t y �. <br />20 N k i,—,' ,%A ( <br />r Ln <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />Invoice # <br />Check # gLl <br />Rec ived By: <br />SITE ADDRESS .11 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 19 ICXo <br />l O ��� <br />.�,►C� _ <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />(2,0) 2� <br />H5 -00—(l <br />PHONE #2 EXT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/ice a, \S; n_ C>r` Q VJ <br />`/t�lV \")�/+vy, i <br />tv �(`-_-/—r-> �CHECK If BILLING ADDRESS <br />B�U+S`INESS NAME <br />t� <br />1,1"�j"y <br />4JQ-- <br />PHHO`N•E�# `� % cy ExT• <br />kJSJ i i J <br />HOME <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: <br />FAX # <br />Date Service Completed (if already comple(ed): <br />SERVICE CODE: <br />P i E:... <br />CITY / k1 t y �. <br />STATE ZIP gscl G l <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 application and that the w to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDEW, s. <br />APPLICANT'S SIGNATURE: DATE:. <br />PROPERTY / BUSINESS OWNER❑ OPERA MANAGER ❑ OTHER AUTHORIZED AGENT Ar ' - ir�R.T ES jZp . <br />If APPLICANT is not the BIL9WG 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: � � C.; '� p �i1 �,ij "—'c .- n'q- //lr{ <br />Fs- ( 0 <br />� <br />COMMENTS: CA= v—� S''/ iN ��C �1 %� fc. N ' --re-Q `� Y 47 S <br />S ✓('fi <br />og"j. P«��Vr> --V� S,; <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already comple(ed): <br />SERVICE CODE: <br />P i E:... <br />Fee Amount:Amount <br />' <br />Paid %S �� <br />Payment Date 2 <br />Payment Type � <br />Invoice # <br />Check # gLl <br />Rec ived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />