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JAN JOAQUIN k-OUNTV ENVIRONMENTAL HEALTH DEPARTMENT <br />r SERVICE REQUEST <br />Type of Business or Property <br />low <br />BUSINESS NAME <br />6G T"(1.t71� � 12`/�% Tlic, <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />3t D /?-A j& <br />(-c (r' - f c�t-c- I ' c� <br />FAX # <br />(V6 , (- -r alb <br />CITY /a ap boo Pr <br />STATE C+ ,/) ZIP CIS -6 7 <br />OWNER / OPERATOR <br />1�',l L"V9.114,', <br />❑ <br />C � Rates >! � X <br />�� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME C ��12crn <br />2 t -7 I <br />ASSIGNED TO' !^' �j_. t) L�c <br />SITE i 0 RESS <br />S <br />DATE: .) ce <br />FXA Ir l A-)rvl <br />SERVICE CODE: l�3 �7 <br />Tv`� 'T <br />7 5 3- 7 <br />Street Number <br />Dlrectlon <br />treet Name <br />CI <br />ZiCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Check # <br />3 '�;0 <br />Received By: �Zr <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATIO CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />RAti J�/ /S VVW k) <br />HECK If BILLING ADDRESS <br />/ -0& / r_ <br />BUSINESS NAME <br />6G T"(1.t71� � 12`/�% Tlic, <br />COMMENTS: <br />PHONE# EXT. <br />n 1(0 631-1300 11 dA I <br />HOME or MAILING ADDRESS <br />3t D /?-A j& <br />(-c (r' - f c�t-c- I ' c� <br />FAX # <br />(V6 , (- -r alb <br />CITY /a ap boo Pr <br />STATE C+ ,/) ZIP CIS -6 7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 />1 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 FEDE L laws. <br />APPLICANT'S SIGNATURE: ���� DATE: <br />PROPERTv/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTIIORIZEDAGENT 9 r/ irrMywb%2—+ <br />,f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 time it is <br />provided to Ane or my representative. RECE1�/E <br />TYPE OF SERVICE REQUESTED: �� K l✓ 1-� 7C jT <br />,. <br />200$ <br />COMMENTS: <br />GooSAN pl <br />(-c (r' - f c�t-c- I ' c� <br />Hog <br />1 1 <br />1�',l L"V9.114,', <br />k f { Y•{}1 <br />ACCEPTED BY: V L <br />EMPLOYEE #: <br />- <br />DATE: 2 <br />ASSIGNED TO' !^' �j_. t) L�c <br />EMPLOYEE #: <br />��-7-& <br />DATE: .) ce <br />Date Service Completed (if already Completed): <br />SERVICE CODE: l�3 �7 <br />P E: �G <br />Fee Amount:4,;�,q 4. (,,) X ,,2 450 <br />Amount Paid (�, ;E , <br />Payment Date <br />2 y to 8 <br />Payment Type ✓ <br />Invoice # <br />Check # <br />3 '�;0 <br />Received By: �Zr <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />