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NAN JOAQUI: COUNTY ENVIRONMENTAL HEAL'T J DEPARTMENT <br />SERVICE REQUEST <br />Type of business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />!� <br />Q�\NGo <br />BUSINESS NAME�n <br />OERJ OPERATOR. <br />PHONE# <br />Err. <br />CHECK If BILLING ADDRESS <br />( <br />(?c<% ) <br />G Z S�7 <br />HOME or MAILING ADDRESS <br />FACILITY NAME <br />FAX # <br />EMPLOYEE #: <br />_wrrA DATE: 5 <br />Date Service Completed (if already completed) <br />CITY <br />SITE ADDRESS <br />pp <br />�JO <br />(ZJ <br />ZIP � Ql <br />�C� <br />:;� 1;, <, <br />Street Number Direction <br />Street Name / <br />d O <br />, <br />Ci Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Payment Type ✓ <br />L <br />Check #y';)� <br />Received By: 2lti <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 EXT. <br />APN # <br />0� 0 <br />LAND USE APPLICATION # <br />(2t it) C 4 T S / <br />(L <br />I <br />� "I / <br />/// <br />PHONE #2 EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR:j <br />1 <br />CHECK If BILLING ADDRESS <br />COMMENTS: <br />!� <br />Q�\NGo <br />BUSINESS NAME�n <br />PHONE# <br />Err. <br />l� <br />(?c<% ) <br />G Z S�7 <br />HOME or MAILING ADDRESS <br />I DATE: e� <br />FAX # <br />EMPLOYEE #: <br />_wrrA DATE: 5 <br />Date Service Completed (if already completed) <br />CITY <br />P ! E: •L� <br />STATE �, <br />ZIP � Ql <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, ATE and F ERAL laws. <br />�^ 1 <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ElOPERATOR i MANAGER ❑ , <br />OTHER AUTHORIZED AGENT LLQ]/ <br />If APPLICANT is not the BaLiNGPARTY 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 <br />`ipiironmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />!� <br />Q�\NGo <br />SoP <br />SP �N`I�NO�PP <br />ACCEPTED BY <br />MPLOYEE #: <br />I DATE: e� <br />ASSIGNED TO: 1 <br />EMPLOYEE #: <br />_wrrA DATE: 5 <br />Date Service Completed (if already completed) <br />SERVICE CODE: J'i G <br />P ! E: •L� <br />Fee Amount: i — <br />Amount Paid <br />$ act LJ <br />Payment Dailvte <br />I . <br />Payment Type ✓ <br />Invoice # <br />Check #y';)� <br />Received By: 2lti <br />EHD 48-02-025 ,SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />