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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />db SERVICE REQUEST db <br />Type of Business or Property <br />FACILITY ID # <br />PHONE #) EXT. <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CITY cJ T"�On $TATE ZIP 9 sa o s - <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �� ♦�'` � � 1 <br />SAN JOAQUIN COUNT`/ <br />SITE ADDRESS /� ��L] Crt aYl �h�tt <br />Street Number Direction J <br />Street Name <br />' " <br />`3Tcye- y Cit 9s'.IL 0(p <br />city Zip Code <br />HOME or MAILING ADDRES (If Different from Site Address) <br />Street Number <br />DATE: f - t3 <br />Street Name <br />CITY Wm lc <br />STATE ZIP <br />PHONE #1 EXT. <br />(-CFj) &) d-710,-4-/ <br />APN # <br />1�3- /3a -t1 <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />P I E: <br />BOS DISTRICT <br />LOCATIONr CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CNECK If BILLING ADDRES <br />REQUESTOR �►y/�/�� <br />BUSINESS iVAMER i V.c ��� ra.c_ � <br />PHONE #) EXT. <br />HOME or MAILING ADDRESS <br />W w. %r. <br />FAx # <br />()- <br />CITY cJ T"�On $TATE ZIP 9 sa o s - <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 preparedthis app c tion and that the work to be performed will be done iccor nce with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S T n aand FEDERAL la <br />APPLICANT'S SIGNATURE: �/% W�- DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGE <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. <br />_.. <br />TYPE OF SERVICE REQUESTED: �� ( ` � �[ T <br />T -x1 1 Iw •- <br />RECEj-VED <br />COMMENTS: <br />JUN 12 2007 <br />SAN JOAQUIN COUNT`/ <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 0(-c vet <br />EMPLOYEE #: C> �; Z_/ <br />DATE: f - t3 <br />ASSIGNED TO: <br />EMPLOYEE M C)7LS'3 <br />DATE: &, C <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />(4 <br />P I E: <br />Fee Amount: _ ��S ® U <br />Amount Paid <br />�U <br />Payment Date y p <br />Payment Type <br />Invoice # <br />Check # `( L f <br />Received By:�� <br />EHD 48-02-025 C\[J' SR FORM (Golden Rod) fi <br />REVISED 11/17/2003 <br />