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A <br />`` ` <br />i S hem- i's �j 1 <br />SAN JOAQ!IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT <br />SERVICE REQUEST <br />T yp a B st^as o <br />BUSINESS NAmV <br />PHONE /� En, <br />FAC)L?TY'D # <br />_ SERVICE REQUEST # <br />�P.operty <br />RECEI <br />(6SQ <br />�oG 3849 <br />OWNE / OPERATOR <br />CI <br />2(q q _ HECK if BILLING ADDRESSEd <br />�ALILITYNaI:;E Q2O1-5I M <br />.L.J.L.-:��J.t�..l�__.....�__,. <br />..,..�`�.�..._1,�. .. <br />_�` �.... <br />SITE ADDRESS 2- <br />SAN JOADUN COUNTY <br />E4V1R0NMENT/.L <br />DEPARTMENT <br />2�5 <br />Street Number <br />Direction Street Name <br />CityZip ode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />APPROVED BY: <br />Cb� <br />Street Number <br />EMPLOYEE #: O <br />Strett Name <br />CITY <br />6 `/ <br />W07/11 <br />STATE ZIP (; <br />PHONE#1 9l,q <br />EXT* <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />(5\0) 219 - 4-' <br />EXT. <br />SERVICE CODE: <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAmV <br />PHONE /� En, <br />HOME Or MAIL„^IG ADDRESS9-T- AIM <br />85 <br />FAx #)�b <br />CITYn m l STATE ` -ZIP�r <br />BILLING ACKNOWL'9,15GEMENT: 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 SIGNATURRE: �t DATre-:� <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required 7'fr1e <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 HEAI.TH 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 />YMENT <br />COMMENTS: <br />RECEI <br />Nov - 8 2011 <br />SAN JOADUN COUNTY <br />E4V1R0NMENT/.L <br />DEPARTMENT <br />- <br />HEALTH <br />APPROVED BY: <br />Cb� <br />EMPLOYEE #: O <br />DATE: <br />6 `/ <br />W07/11 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />( t 67f1I <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P <br />Fee Amount: <br />3 J� <br />Amount Paid <br />Payment Date L� <br />Payment Type <br />invoice # <br />Check # h l 7 <br />Received By: <br />EHD 48-01-025 <br />aFuicGn t;_F_n� <br />SERVICE REQUEST FORM <br />