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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />pe of Business or PropertyACILITY <br />ID # <br />SERVICE REQUEST # <br />` <br />� 3 <br />.�. .: ..- <br />.► � . _ �`t W i► I ���� %10_044"� <br />W ER OPERATOR !)l4 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Ir <br />SITE ADDRESS <br />I <br />NVIRONMENTALHEA►LTH <br />1-71 StmetNumber cStion <br />t <br />4 <br />Ho or /SI�Di NG ADt Site Address) <br />(�+, <br />Street Number Sheet Name <br />[` p <br />TATE ZIP <br />EMT. <br />APN # <br />DATE: �D <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />EMPLOYEE #: <br />BOS DISTRICT <br />LOCATION CODE <br />\ % . Q CONTRACTOR / SERVICE REQUESTOR <br />►'1k - <br />_ <br />_� ..� � i111MUffift � 1 .. �. ! 1� <br />�� > <br />�. i �E� <br />.�. .: ..- <br />.► � . _ �`t W i► I ���� %10_044"� <br />t <br />�d1 rid <br />_ _- <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAR7'MEN'I' hourly charges associated with this project <br />or activity will be billed to me or my buses identified on this form. <br />I also certify that I have prepared <br />COUNTY Ordinance Codes, Stand <br />the work to be performed will be done in accordance with all SAN JOAQUIN <br />APPLICANT'S SIGNATU %DATE: <br />PROPF.RTY/BusiNF,SSOWNF.R❑E TOR/1%1- AGER ❑ OT RAUTHORIZEDAG:ENT <br />!f APPLICANT is not the BILLING PARTY. roof of authorization: to sign is required Tarte <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAI. HEALTII DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. 1nr! f%M% 10M <br />TYPE OF SERVICE REQUESTED: <br />1&7— Pi4jr <br />COMMENTS: <br />ri' <br />IyECie, rED <br />A <br />OCT 2 0 W4 <br />ocr <br />2eh' <br />s4"tO� OUN®?014 <br />NVIRONMENTALHEA►LTH <br />; o°e MEM�'Mr <br />PERMMSERVICES <br />irk <br />ACCEPTED BY: J /Y <br />l✓ f <br />V ! G <br />EMPLOYEE #: <br />DATE: �D <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: i ZU <br />Date Service Completed (if alrCy <br />completed): <br />SERVICE CODE: <br />/ <br />Fee Amount: r3 --� <br />Amount Pa 3?0, 6 <br />1Payment Date <br />Payment Type <br />Invoice # <br />Check # 5- 7 <br />Rec ved By: F*d <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />