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L� <br />SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTH IMARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />sI-4.41OWNER/ <br />NNE <br />EXT. <br />HOME or MAILING ADDRESS �� <br />.a?e, 9 6 -57C � C y <br />/A <br />!ry <br />OPERATOR a� <br />p <br />L• <br />S 7 / ✓t� ^ p � A /lv 1 L <br />/' <br />CD /t /� p CHECK If BILLING ADDRESS® <br />T <br />�C/ <br />FACILITY NAME <br />STATE CA <br />SITE ADDRESS <br />I <br />M e A t✓t: <br />Fee Amount: <br />Amount Paid <br />Street Number <br />Directio. <br />Street Name <br />Invoice # <br />a 1 <br />--ZID Code <br />HOME or MAILING ADDRESS (If Different from Site Address)'Ll <br />Street Number <br />ame <br />CITY <br />STATE I t0`'9 <br />PHONE #1 ExT. <br />(a0�► `��1- 8708 <br />APN # <br />b77- zFa-va <br />LAND USE AWId�"iJ(1 <br />PHONE #2ExT• <br />(a 101) //091- asgo <br />BOS DISTRICT <br />LOCATioN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ly� /1 // n A 5 O C) -.z1-,, <br />41-1, <br />CHECK if BILLING ADDRESS O <br />BUSINESS NAME C N N,,�y4 <br />NNE <br />EXT. <br />HOME or MAILING ADDRESS �� <br />.a?e, 9 6 -57C � C y <br />/A <br />!ry <br />FAX# <br />(nj6) <br />'70 5- y 7 78 <br />CITY s X A 149,1/ �1 O <br />STATE CA <br />ZIP 95-g3 y <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. c? <br />APPLICANT'S SIGNATURE:( �j�,��3," r DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER pl OTHER AUTHORIZED AGENT ❑ <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 t0 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: S ? Lr <br />COMMENTS: <br />ACCEPTED BY: o L t �t <br />EMPLOYEE #: 0 3 Z 1 <br />DATE: _3 Lc ( O �= <br />ASSIGNED TO: + <br />EMPLOYEE #: 4 �, 3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ; t^L �% <br />P 1 E:� <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />