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SAN JOAQUI�COUNTY ENVIRONMENTAL HEALTHARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />✓ <br />FACILITY ID # <br />USINESS NAME <br />SERVICE REQUEST # <br />c " S i-�C_ <br />f - <br />ExT. <br />)- - 30U <br />5020C)64 1;�v 1 <br />OWNER/ OPERATOR <br />�( _ <br />CO/r6C— 411 <br />OI <br />CHECK If BILLING ADDRESS <br />F i TYNAE <br />(2-,' n V h�cl c� <br />ZIP 3 <br />SITE ADDRESS 31'2 0 <br />EMPLOYEE #: <br />^ 1 <br />(�\�V-+ R-o� <br />1- <br />ASSIGNED TO: �� <br />��a ^ <br />S �' <br />Street Number <br />Direction <br />Street Name <br />2i CodeJ <br />HOME/oar MAILING ADDRESS (If Difffeeren from Site Address) <br />Date Service Comple d (if already completed): <br />TC) -50X L \ <br />Street NumberF <br />P E: <br />Street Name <br />CIT' <br />e <br />Payment 3 z -- <br />STATE ZIP <br />PHONE #1 <br />ExT• <br />APN # <br /># <br />LAND USE APPLICATION71 <br />Received By: ,3 <br />PHONE #2 <br />lq (l� ► g'� 3 3 80 <br />T• <br />BOS DISTRICT <br />LOCATION CODE <br />11- <br />CONTRACTOR / SERVICE REQUESTOR <br />EQUESTOR <br />✓ <br />CHECK If BILLING ADDRESS <br />USINESS NAME <br />MAR � 6 2012 <br />PHONE# <br />s- <br />ExT. <br />)- - 30U <br />HOME or MAILINGDDRESS <br />C, <br />FAX # <br />( <br />) �,-7-7—OOS_ S <br />CITY <br />STATE <br />ZIP 3 <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 aws. <br />APPLICANT'S SIGNATURE: 4=1LS DATE: 5 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ nA.NAGEOTR AUTHORIZED AGENT U <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 />TYPE OF SERVICE REQUESTED: T <br />/' J / j� <br />pAXCF IV ED <br />COMMENTS: <br />MAR � 6 2012 <br />SAN JOAQUIW GOUFIf't <br />`"NiH DEP RTDtENT <br />„FAI'i <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: / <br />ASSIGNED TO: �� <br />EMPLOYEE #: Y -b <br />/ <br />DATE: <br />> <br />b <br />Date Service Comple d (if already completed): <br />SERVICE CODE: <br />r�/ <br />y <br />ClDate <br />P E: <br />Fee Amount: <br />Amount Paid 15 3-7s-- <br />Payment 3 z -- <br />Payment <br />Payment Type ✓ <br />Invoice # <br />Check # `p� S <br />Received By: ,3 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />