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SAN JOAQU&OUNTY ENVIRONMENTAL HEALTH OARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAMEPHONE <br />L �draGt✓p �Q.c 9 �%,a <br />FACILITY ID #G <br />HOME or MAILING ADDRESS ` <br />SERVICE REQUUEST # <br />CITY �/� ; ;i STATE ZIP <br />DATE: <br />ASSIGNED TO: t �- , T4 <br />EMPLOYEE #: <br />L/ / S 4D <br />OWNER! 0PERATnR <br />CHECK if BILLING ADDRESS <br />L <br />Fee Amount: �' <br />Amount Paid <br />FACILITY NAME <br />Payment Date <br />Payment Type <br />SITE ADDRESS <br />Check # <br />Received By: <br />tree[ Number <br />Direction <br />Street Name <br />Ci <br />~ Zip Code__ <br />WxE Oi MAILING ADDRESS (if Different from Site Address) <br />`t LIQ q <br />Street <br />` `' �''Street Nam <br />CI'.t�... <br />SW� ZIP <br />L( <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LoCAI iON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK If BILLING ADDRESS] <br />REQUESTOR '4 ���� <br />BUSINESS NAMEPHONE <br />L �draGt✓p �Q.c 9 �%,a <br /># EXT. <br />Si 22 a(-16 y <br />HOME or MAILING ADDRESS ` <br />FAX # <br />CITY �/� ; ;i STATE ZIP <br />v <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 laW <br />APPLICANT'S SIGNATURE: r DATE: 3i % <br />PROPERTY/ BUSINESS OWNEf OPERATOR/ MANAGER 13 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />AfAY3,20 <br />'',DA <br />"� 0o NES u <br />xi <br />�TME1? <br />ACCEPTED BY: ' A <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: t �- , T4 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />r^ <br />SERVICE CODE: 0(c, <br />PIE: •`� / <br />Fee Amount: �' <br />Amount Paid <br />_ J <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />