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• • <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />2-0`1 <br />Type of Business or'Property « <br />FACILITY ID # <br />R <br />SERVICE REQUEST.# <br />ff6od <br />2Do <br />ACCEPTED BY: <br />�Z <br />OWNER/ OPERATOR <br />ASSIGNED TO: <br />EMPLOYEE #: 6j64Z <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: IP <br />CL <br />/ E: Z Q <br />Fee Amount: 'A <br />SITE ADDRESS ��� <br />I <br />3 S <br />Paymenf Date <br />Lf 3 0 <br />Payment Type ✓ <br />Street Number Direction <br />Street me <br />Received By: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />(261 402— <br />PHONE#2 EXr• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME PHONE Err. <br />FLIM Mite)1 <br />HOME or MAILING ADDRESS FAX # <br />(&3) 460 - 342 <br />CITY STATE CA <br />ZIP l <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: �� f ls� V DATE: 3 • cf-1 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTS) I Ili ff Y"E E <br />If APPLICANT 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: 0 ; <br />R <br />COMMENTS: <br />APR 0 0 <br />SAN JOAQUIN TM <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: 6j64Z <br />DATE: <br />Date Service Completed (if already completed): I <br />SERVICE CODE: IP <br />/ E: Z Q <br />Fee Amount: 'A <br />Amount Paid <br />3 S <br />Paymenf Date <br />Lf 3 0 <br />Payment Type ✓ <br />Invoice # <br />Check # 3 9 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />