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JAN JOAQUIN UOUNT 'N,VI OR NMEN AL�HEALTH�hEPARTMENT <br />%Io+� �� * � ZZERVI`CEE REOUEST <br />Type of Businesssor Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE / EXT. <br />V (p <br />HOME or MAIL ADDRESS <br />Xs a Q1 1 C� <br />FAx# <br />�P—b4) 466-svo <br />OWNER/ OPERATOR <br />/Nkk l I <br />ZIP <br />1. STATE (016L, <br />CHECK if BILLING ADDRESS <br />FAt.ILfiY NAME <br />S <br />�N� AO �pRPtt3``��S <br />N��SNO <br />ACCEPTED BY: <br />SITE ADDRESS <br />� <br />� /� � /�� /•� �� <br />c <br />DATE: 17 12/0 <br />�� <br />C,� <br />��� � �_ <br />Street Number <br />Direction.,.] <br />Date Service Completed (if already completed): <br />St me <br />1q e <br />Ci <br />Fee Amount: <br />Zi Code <br />HOME orMAILINGADDRESS (If Different from Site Add ss) <br />S <br />- <br />Payment Type <br />✓ <br />Invoice # Check # "7 <br />Street Number <br />Street Name <br />CITY L l !� :� 1� �1 <br />STATE (- � ZIP <br />7S z ,� 6 <br />PHONE #1 ExT• <br />( C <br />APN # <br />LAND USE APPLICATION # <br />> <br />PHONE#2 ExT• <br />) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR i <br />LA-- <br />CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME 0 / <br />(G3a l <br />PHONE / EXT. <br />V (p <br />HOME or MAIL ADDRESS <br />Xs a Q1 1 C� <br />FAx# <br />�P—b4) 466-svo <br />CITY Jq�L <br />ZIP <br />1. STATE (016L, <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, STATE and FEDERAL laws; <br />APPLICANT'S SIGNATURE:1�(t �� `� I �l vl DATE: <br />PROPERTY/ BUSINESS OWNEP6 OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title <br />AITTHORIZATION 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 ate same time it is <br />provided to me or my representative. N <br />--- - _ It, nG n <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />`l <br />SSP O\JNN <br />30 <br />P <br />S <br />�N� AO �pRPtt3``��S <br />N��SNO <br />ACCEPTED BY: <br />©L vsr— <br />EMPLOYEE #: 3 / <br />DATE: 17 12/0 <br />ASSIGNED TO: <br />C,� <br />EMPLOYEE #: U 373 <br />DATE: 9 2 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />1q e <br />PIE. t <br />Fee Amount: <br />2.7 c U(� <br />Amount Paid <br />Payment Date <br />Payment Type <br />✓ <br />Invoice # Check # "7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />