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,JAN JOAQUIN UOUNITY ENVIRONMENTAL 11EALTH DEPARTMENT <br />0 SERVICE REQUEST 4) <br />Type of Business or Property <br />u <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: <br />MYIVENT <br />RECEIVED <br />AUG 10 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY: <br />OWNER/ OPERATOR 'f <br />EMPLOYEE #: 6(� <br />DATE: _ <br />ASSIGNED TO: <br />V aCl Pu�,�t� <br />�i�.K,l,c�w. Sc�tJIGt, 7r <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />v '-t l <br />P 1 E: <br />SITE ADDRESS 1ST 1 <br />_ ®� <br />t"j�� <br />�� l`' 1x— .►. <br />Payment Date <br /><> <br />�.�oclC�a h <br />�jlZ tib°' <br />Street Number <br />Direction <br />Check # <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address)�_ <br />Ft' 16 <br />V- Ch c\t <br />�I <br />Street Number <br />Street Name <br />CITY <br />STATE <br />CIS <br />ZIP <br />qxzo b <br />PHONE #1 <br />ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />'1'►� (k�- F1,�Soh <br />BUSINESS NAME f� ('� 1 / <br />v cc,� Poc��t .Z C 2'T' -Jt l,� w. fie! U it-= <br />HOME or MAILING ADDRESS <br />(s c, r-7 C;r�lc <br />CITY Sv,C-k --I, <br />CHECK If BILLING ADDRESS <br />PHONE # I EXT. <br />FAx # <br />(z-9) qY5r, <br />STATE CM_ ZIP <br />-C,7-4's- <br />ST Lolo <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 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 />APPT.Tr ANT5C CT(iNATTTRF.•✓ /�� r.... �� to I d <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER C( 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 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 />u <br />COMMENTS: <br />MYIVENT <br />RECEIVED <br />AUG 10 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ACCEPTED BY: <br />EMPLOYEE #: 6(� <br />DATE: _ <br />ASSIGNED TO: <br />EMPLOYEE #: —7 3 <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: �? <br />_ ®� <br />Amount Paid <br />Payment Date <br /><> <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 />