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SAN JOAQUINOUNTY ENVIRONMENTAL HEALT"DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-T <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE REQUEST # <br />0 <br />PHONE# EXT. <br />( ) <br />HOME or MAILING ADDRESS <br />(A- <br />FAX # <br />OWNER / OPERATOR <br />CITY <br />CHECK If BILLING ADDRESS <br />�--- <br />Pic <br />OCT - 1 2010 <br />FACILITY NAME <br />SITE ADDRESS <br />1 <br />01,S2—q2— <br />SMektNJtfiber Direction <br />Street Name <br />0,32-/ <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />EMPLOYEE #: <br />f T Z 2i <br />Q <br />Street Number <br />SERVICE CODE: 0 6 <br />Street Name <br />CITY— <br />1-bAL <br />ZZ <br />STATE ZIP <br />Z <br />PHONE #1 EXT. <br />APN # <br />Payment Date <br />LAND USE APPLICATION #!= <br />(;zoy) '� l 5<- 7 6� <br />Invoice # <br />Check # <br />PHONE #2 EXT. <br />Received By: <br />BO S DISTRICT <br />LOCATION CODE <br />(;-)N) —7 — `' <br />® CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS_❑ <br />BUSINESS NAME <br />', lA <br />PHONE# EXT. <br />( ) <br />HOME or MAILING ADDRESS <br />(A- <br />FAX # <br />CITY <br />STATE 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an4XE9qRAL laws. <br />11 <br />APPLICANT'S SIGNATURE: za�c�DATE:©" <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ® 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: (k S T <br />C C) AJ S �- Q <br />PAYMENT <br />RECEIVED(` <br />COMMENTS: <br />OCT - 1 2010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />D C— 10 -cc # 02-4 <br />EMPLOYEE #: <br />0,32-/ <br />DATE: /0 % U <br />t <br />ASSIGNED TO: <br />G4 -- <br />EMPLOYEE #: <br />f T Z 2i <br />DATE: l0 O <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0 6 <br />PIE: 23 <br />Fee Amount: <br />ZZ <br />Amount <br />Paid <br />Payment Date <br />Payment Type <br />-k S <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />