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SAN JOAQUIN 9UNTY ENVIRONMENTAL HEALTH%PARTMENT <br />SERVICE REQUEST <br />Type usiness P operty <br />� <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />- I D4J <br />RECEIVED <br />JUL 3 0 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />t) L -C $24 <br />OWNEO OPERATOR <br />DATE: 7 3c) o <br />1 <br />CHECK If BILLING ADDRESS ❑ <br />C ,4G (7 <br />EMPLOYEE #: l [..F a -?—DATE: <br />FACILITY NAME <br />WV <br />(if already completed): <br />SITE ADDRESS <br />C} <br />P 1 E: `1 3 Q <br />Fee Amount: <br />StreetNumber <br />Di ion <br />edk <br />Invoice # <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Received y: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />1) 23-3-3v 7 0 <br />Lf 7 -- 280---06, <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />n CONTRACTOR / SERVICE REQUESTOR I, <br />REQUESTOR <br />CHECK If <br />EXT. <br />BUSINESS NAME <br />HOME or MAILING ADDRESS r 'fa I - <br />CITY �-I-, rl jL t! STATE ZIP Ce- �_Y� <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 thi plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar s, TATE and FEDE ws <br />APPLICANT'S SIGNATURE: '^ DATE: _ <br />9 <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 <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 JOAQUfN 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 />� <br />COMMENTS: <br />RECEIVED <br />JUL 3 0 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />t) L -C $24 <br />EMPLOYEE #: 0 2 2�- <br />DATE: 7 3c) o <br />1 <br />ASSIGNED TO: <br />C ,4G (7 <br />EMPLOYEE #: l [..F a -?—DATE: <br />3 1) (7 <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />C} <br />P 1 E: `1 3 Q <br />Fee Amount: <br />Amount Paid <br />(� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 3,�, <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />