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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST • <br />Type of Business or Property - <br />CHECK If BILLING ADDRESS <br />FACILITY ID # _ <br />SERVICE REQUEST # <br />EXT. <br />HOME or MAILIN AD KESS <br />FAX # <br />(,.V9) <br />S�Gr, 4- F Q ( 3 <br />OWNER/ OPERATOR <br />ZIP <br />CHECK If BILLING ADDRESS <br />ENVIRONMENTAL <br />FACILITY NAME <br />HEALTH DEPARTMENT <br />SITE ADDRESS <br />�31 <br />64 <br />�" <br />Street Number Dimon/ <br />Street Name "� ' <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />' <br />ASSIGNED TO: <br />Street Number <br />Street Name <br />CITY •� �% <br />1 NEXT. <br />STATE <br />ZIP <br />#1 <br />mM-'/ / � <br />qPN # <br />2 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />l ) <br />Amount Paid <br />BOS DISTRICT�' <br />- ] <br />LOCATION CODE <br />ILI-It' , <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR // <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME t _ <br />PHONE# <br />EXT. <br />HOME or MAILIN AD KESS <br />FAX # <br />(,.V9) <br />46'1���� <br />CITY t ,1 . 7d.3TATE <br />ZIP <br />v • - $ -- <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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Uk'L DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 9 <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 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. n <br />TYPE OF SERVICE REQUESTED: lJ <br />RE jd <br />COMMENTS: <br />OCT 19 200 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: j O <br />' <br />ASSIGNED TO: <br />EMPLOYEE #: <)-7 <br />DATE: <br />Date Service Complete <br />(if already co ted): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />5- % <br />Amount Paid <br />a� s <br />Payment Date ��' �`� 116, <br />Payment <br />Payment Type <br />Invoice # <br />Check # l Z �,� <br />Received By: 1V t_T <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />