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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT�EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />PHONE # <br />ExT. <br />� � <br />0 ll`)$� <br />Sea) 5 (413% <br />, <br />FAX # <br />DATE: <br />`>� <br />(9 U.) <br />OWNER / OPERATOR <br />CITYS TE <br />CHECK If BILLING ADDRESS <br />``__ <br />�Y\ <br />Amount Paid <br />�Cj <br />FACILITY NAME <br />Ss a <br />Payment Type " / <br />SITE ADDRESS <br />UJ <br />1 <br />Received By: L—� <br />"1 to <br />C) Street Number <br />Direction <br />1 Street Name <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />m f <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />oec �er�o <br />Q <br />PHONE #1 EXT. <br />qpN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICTLOCATION <br />CODE <br />(at) �- - (Z� <br />11 <br />—�3 ::1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />PAYMENT <br />COMMENTS: <br />BUSINESS NAME <br />PHONE # <br />ExT. <br />EMPLOYEE #: /^� <br />E�I/ <br />0 ll`)$� <br />ASSIGNED TO: e �r4 <br />HOME or MAILING ADDRESS <br />FAX # <br />DATE: <br />`>� <br />(9 U.) <br />6'k-4=, ` ai U3 <br />CITYS TE <br />ZIP-3� <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ��'�? �" DATE: O <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT(y y s <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required m Title "S <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: -� <br />PAYMENT <br />COMMENTS: <br />MAY 5 2008 <br />SAN JOAQUIN COUNTY <br />14EALTH DEPARTM NT <br />ACCEPTED BY: o L -C LC , -- <br />EMPLOYEE #: /^� <br />E�I/ <br />DATE: �' Q <br />ASSIGNED TO: e �r4 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed if already completed): <br />SERVICE CODE: qlp <br />PI : 23 ani <br />Fee Amoun : �q t �Z z� <br />Amount Paid <br />�Cj <br />Payment Date <br />Ss a <br />Payment Type " / <br />Invoice # <br />Check #oD C(o <br />Received By: L—� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />