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SAN JOAQL16COUNTY ENVIRONMENTAL HEALTIREPARTMENT <br />SERVICE REQUEST cs (2-0 0 <br />Type of Business or Property <br />FACILITY ID # <br />�l <br />SERVICE REQUEST # <br />JLbs mai <br />ACCEPTED BY: <br />P ONE - 1 /' , T' <br />l7 <br />��i3 <br />OWN / OPE RATO <br />FAX # <br />CHECK if BILLING ADDRESS <br />EMPLOYEE #: 1 <br />1 <br />DATE: <br />CITY 1 } <br />L—� V Z� Y�� ✓v` <br />F UTY NAME <br />SERVICE CODE: (p' <br />PIE: 12-31 —3 ` I <br />Fee Amount: <br />i S t�t) <br />! <br />IL <br />Payment Date �� I �ri <br />Payment Type <br />VInvoice <br /># <br />SITE DDRESS <br />Received By: <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />3 <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( i <br />C) 0-3 <br />PHONE #2 Err.. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR U <br />REQUESTOR�b,, <br />CHECK If BILLING ADDRESS <br />�l <br />BUSINESS NAME ., — <br />I C / til ', <br />ACCEPTED BY: <br />P ONE - 1 /' , T' <br />l7 <br />HOME or MAILING AD R S <br />DATE: A T <br />FAX # <br />C"-- <br />EMPLOYEE #: 1 <br />1 <br />DATE: <br />CITY 1 } <br />L—� V Z� Y�� ✓v` <br />SC'.. b ZIP-) `\ 5l <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 <br />or 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 Fe RAL laws. <br />APPLICANT'S SIGNATURE: i DATE: G , <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR"/ MANAGER ❑ OTHER AUTHORIZED AGENT LJ <br />If APPLICANT is not the BILLINGPARTY, proof of authorization to sign is require 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. <br />TYPE OF SERVICE REQUESTED: co <br />COMMENTS:REcre�NT <br />RECEIVE[) <br />VE[) <br />NOV 14 20;� <br />SAN JOAQUIN ENVIROME COUNTY <br />IAN <br />ACCEPTED BY: <br />C,� <br />EMPLOYEE M <br />DATE: A T <br />ASSIGNED TO: <br />C"-- <br />EMPLOYEE #: 1 <br />1 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: (p' <br />PIE: 12-31 —3 ` I <br />Fee Amount: <br />i S t�t) <br />! <br />Amount Paid I t -- <br />r <br />Payment Date �� I �ri <br />Payment Type <br />VInvoice <br /># <br />Check # i 7 ,f <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />