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.SAN JOAQUIN COUOY ENVIRONMENTAL HEAUM D*RTMLN'I' <br />SERVICE REQUEST <br />Type of Business or Property <br />ENT <br />Er f YM <br />COMMENTS: <br />FACILITY ID # <br />SERVICE REQUEST # <br />W07y:.�2��3'4 <br />S� �OAQUIN OOv CE <br />RH ONISION <br />OWNS PERATO <br />ONME T�- HEP <br />ENV1R <br />APPROVED BY: <br />rnrn <br />CHECK It BILLING ADDRESS►�I <br />ASSIGNED TOi/ j <br />EMPLOYEE #: o t(� C, - DATE: e27&,7 G, <br />Date Service Completed (it already completed): <br />SERVICE CODE: le ffl PIE:,23 6k <br />FACILITY NAME <br />Amount Paid .'fp-j" <br />Payment Date. <br />SITE ADDRESS 70 <br />Invoice # <br />Check # <br />Received By: <br />Street Number <br />Dlrectlon <br />Street Name <br />CII <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BCIS DISTRICT <br />LOCATION CODE <br />CONTRACTO <br />REQUESTOR <br />CE REAQURSTOR <br />CHECK It BILLING ADDRESS❑ <br />BUSIN�FSS NA E c — /�PHONE ExT. <br />HOME or MAILING ADDRESS FAX # <br />LD�,,� S C� (ze ?) <br />CITY C�r ti.. Ir• �. \ STATE -,A ZIP <br />BULLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 rite 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, STATC and FEDCRAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 11 OPERATOR/ M NAGER ❑ 0'r1ICR AUTIIORIz1mD AGENT ❑ <br />If APPLICANT is 1101 [lie 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />nrnvirinrl In me nr my renresentaliVe- <br />TYPE OF SERVICE REQUESTED: <br />ENT <br />Er f YM <br />COMMENTS: <br />R� <br />S� �OAQUIN OOv CE <br />RH ONISION <br />ONME T�- HEP <br />ENV1R <br />APPROVED BY: <br />EMPLOYEE #: DATE: -2-1'2-; C� <br />ASSIGNED TOi/ j <br />EMPLOYEE #: o t(� C, - DATE: e27&,7 G, <br />Date Service Completed (it already completed): <br />SERVICE CODE: le ffl PIE:,23 6k <br />Fee Amount: <br />Amount Paid .'fp-j" <br />Payment Date. <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6.5-02 <br />