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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />i SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS El <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />HO or MAILING ADDRESS <br />t04- <br />9 EC E I VED <br />2 1 2006 <br />SAN JO.,'N JUIN COUNTY <br />ENVI,PONMENTAL <br />HEALTH DEPARTMENT <br />-3e-" <br />CITYS <br />�i" i ae <br />TE ZIP <br />9 L505 <br />OWNER/ OPERATOR <br />#: �3 L <br />DATE: / ®ks <br />, ^ wog or ^ <br />`� F'% -DaY) I <br />V '�` <br />�;,� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: ct 2-t U <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P / E: 23_ p� <br />SITEADDRESS 1qJ0 `tie c-oL( 541 <br />CJI <br />'�'�CCIG�C►'t jZ f S <br />Street Number Direction Street Name <br />city Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Invoice # <br />Check # <br />Street Number <br />Received By: G <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(203)i3 I-Iq Q <br />I 10 1- <br />2!a -o/ <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />-2- <br />LOCATION CODE <br />? 2 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU STOR <br />�� ` C5 � <br />CHECK If BILLING ADDRESS El <br />BUSINES AME ^l <br />-EkiV)rcl� -PV1 <br />COMMENTS: <br />PHONE# EXT. <br />(95i �c7 <br />HO or MAILING ADDRESS <br />t04- <br />9 EC E I VED <br />2 1 2006 <br />SAN JO.,'N JUIN COUNTY <br />ENVI,PONMENTAL <br />HEALTH DEPARTMENT <br />l -�85n <br />CITYS <br />�i" i ae <br />TE ZIP <br />9 L505 <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 prepared thislication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,ftSATE and FEDERAAWS. <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER <br />If APPLICANT is not the BILLING PARTY, proof of authorization <br />DATE: / ( 2 y <br />ZED AGENT eC <br />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 and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />f <br />PAYMENT <br />COMMENTS: <br />9 EC E I VED <br />2 1 2006 <br />SAN JO.,'N JUIN COUNTY <br />ENVI,PONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />L t ��� /► of <br />EMPLOYEE <br />#: �3 L <br />DATE: / ®ks <br />ASSIGNED TO: <br />�;,� <br />EMPLOYEE #: <br />DATE: ct 2-t U <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P / E: 23_ p� <br />Fee Amount:S <br />CJI <br />Amount Paid s <br />Payment Date Zt <br />Payment TypeS <br />Invoice # <br />Check # <br />2 2 <br />Received By: G <br />EHD 48-02-025 SR FARM en' <br />REVISED 11/17/2003 <br />