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SAN JOAQUI�`T OUNTY ENVIRONMENTAL HEAL T DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />p4ms' G4.4 <br />�-"Qka <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />:!:�OZQS <br />OWNER /OP TOR <br />PHONE# EXT. <br />( O <br />HOME Or MAILING ADDR&SS <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />! <br />(Aw w/ — O 0 <br />CITY <br />EMPLOYEE #: _(c �� <br />SITE ADDRESS <br />1. reet Number <br />,VAv' <br />Direction <br />treet Name <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Fee Amount: <br />d— <br />Street Name <br />CITY <br />Payment Date ! - - -)-7 <br />Payment Type <br />STATE ZIP <br />PHONE #'l <br />EXT. <br />APN # <br />(-{ -- 0Z — t)/. <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />) <br />LOCATION CODE <br />3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR� <br />�j <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />d <br />OCT 2 3 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: L I LIC �T <br />PHONE# EXT. <br />( O <br />HOME Or MAILING ADDR&SS <br />DATE: fo 2410 7 <br />! <br />(Aw w/ — O 0 <br />CITY <br />EMPLOYEE #: _(c �� <br />STATE ZIP <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 cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard , STAT nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 91-7/V7 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANA 1-3OTHERAUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required" <br />hile <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: �J <br />PAYMENT <br />COMMENTS: <br />d <br />OCT 2 3 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: L I LIC �T <br />EMPLOYEE #: 3.2 <br />DATE: fo 2410 7 <br />ASSIGNED TO: ['-Cel. <br />EMPLOYEE #: _(c �� <br />DATE: <br />Date Service Completed if already completed): <br />SERVICE CODE: / c� rI <br />P I E: �t30'> <br />Fee Amount: <br />d— <br />Amount Paid <br />4A4?00 <br />Payment Date ! - - -)-7 <br />Payment Type <br />Invoice # <br />Check # L{.pG�� <br />Received By: (42D <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />