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SAN JOAQUOCOUNTY ENVIRONMENTAL HEA DEPARTMENT <br />A SERVICE REQUEST <br />Type Business o Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />PAYMENT <br />SERVICE REQUEST # <br />7 <br />HOME or MAILING ADDRESS� <br />_. <br />OWNE / OPERATO <br />F-95, <br />CITY <br />STATE ZIP 5G?a� <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />dA&� <br />SITE ADDRESS <br />'� <br />ENVIRONMENTAL HEALTH DIVISION <br />��Cit <br />C i Street Number <br />Direction�St <br />t <br />ame <br />u^ <br />EMPLOYEE #: 'L 0 <br />v <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Date Service Completed (if already completed): <br />SERVICE CODE: I <br />Street Number <br />P/ E: C) <br />Street Name <br />CITY <br />Amount Paid <br />STATE ZIP <br />PHO�/NEE#1 EXT. APN # <br />(,om' /) 4? %' 1-25 <br />Payment Type <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( 1 <br />BOS DISTRICT <br />LOCATION CODE <br />n CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />A l / i �,{ <br />(,(��t V �/ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAM ''tel <br />PAYMENT <br />PHONE# EXT. <br />HOME or MAILING ADDRESS� <br />FAX# <br />F-95, <br />CITY <br />STATE ZIP 5G?a� <br />BILLING ACICNOWLI,DGEMENT: 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 applicat' d tha e w to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STDAT and FE M�& <br />APPLICANT'S SIGNATURE: �(� '' <br />/ <br />PROPERTY/tUSINFSSOWNF.R❑ OPERATOR/MANAGER ❑ OTIIFit AUTIIORIZEDACEN �j v l/y <br />ifAPPLICANT 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 HEALTIi 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: <br />S <br />PAYMENT <br />COMMENTS: <br />OCT I.O 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY: <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: <br />u^ <br />EMPLOYEE #: 'L 0 <br />v <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: I <br />�j Qt <br />P/ E: C) <br />Fee Amount: r <br />/ <br />Amount Paid <br />�- <br />Payment Date <br />Payment Type <br />Invoice # -L-TCheck <br /># <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST PORMv <br />REVISED 6-5-02 <br />