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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of usiness or Pr erty <br />—1A -dF [ -r- PAYMENT <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME VT <br />L , I <br />SERVICE REQUEST # <br />� Aw- Ani <br />PHONE <br />C'XN) <br />E.T. <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />F <br />( <br />OWNER/I PERATOR <br />CITY <br />STATE <br />CHECK if BILLING ADDRESS <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />L c/ i 0,4 4 <br />FACILITY NAME <br />DATE: ,-' - �O 7 <br />ASSIGNED TO: <br />V 0 k� F " L <br />(72-1 5 - <br />EMPLOYEE #: <br />DATE: s/2 (& <br />Date Service Completed (if already Completed): <br />SITE ADDRESS <br />1 <br />N ber <br />oqxn" kdreet <br />C� <br />Fee Amount: <br />Street t recti n <br />Name <br />Payment Date S "-c 0-7 <br />City`' Zi Code <br />HOME Or MAILING ADDRESS (If iffere t from Site Addr) <br />ess <br />S ItOb'et <br />Invoice # <br />Check # I/ q1to <br />I Received By: -V. <br />Number <br />Street Name <br />CITY <br />STATE <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />( ) �5 "f "�3�� <br />C (-2- - 0&0 - '-(k <br />PHO 2 xT <br />BOS DISTRICT <br />L <br />LOCATION CODE <br />L' ( Ty <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR' <br />—1A -dF [ -r- PAYMENT <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME VT <br />L , I <br />PHONE <br />C'XN) <br />E.T. <br />HOME or MAILING ADDRESS <br />SAN JOAQUIN COUNTY <br />F <br />( <br />4� <br />CITY <br />STATE <br />ZIP <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 applica to and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT an FEDERAL laws. <br />APPLICANT'S SIGNATURE:���� DATE: / <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BiLLiNG PARTY, proof of authorization to sign is requir d 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: �S'! <br />—1A -dF [ -r- PAYMENT <br />COMMENTS: <br />MAY 2 4 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />L c/ i 0,4 4 <br />EMPLOYEE #: 2 <br />DATE: ,-' - �O 7 <br />ASSIGNED TO: <br />V 0 k� F " L <br />EMPLOYEE #: <br />DATE: s/2 (& <br />Date Service Completed (if already Completed): <br />SERVICE CODE:/ G} �'i <br />P 1 E:E, <br />Fee Amount: <br />S�� <br />Amount Paid � c;)-�� CDL <br />Payment Date S "-c 0-7 <br />Payment Type <br />�._-= <br />Invoice # <br />Check # I/ q1to <br />I Received By: -V. <br />EHD 48-02-025 ,S'R FORM "(Golden Rod) <br />REVISED 11/17/2003 <br />