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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME I <br />FACILITY ID # <br />HOME or MAILING ADDRESS I <br />SERVICE REQUEST # <br />'fb0�,-rAA0 C <br />ACCEPTED BY: ,/1 /I ,/t J <br />EMPLOYEE#: <br />"'2 031C-1(PC1 <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS� <br />FACILITY NAME <br />SERVICE CODE: <br />1 <br />Fee Amount: W152- � <br />Amount Pa' <br />/sa 6 <br />SITEADDRESS 1 610 <br />e�--{ <br />J <br />Invoice# <br />t ,a IF <br />Q(Y� <br />' S l / z <br />slreee Number <br />Direction <br />Streel Name <br />It <br />2i Cotle <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) �C'7 <br />fit <br />t� <br />�t <br />(��E��ON� T Ur <br />Stm t Number <br />Streol Name <br />CITY J kvi 0 <br />tr ` <br />STATE '� ZIP it s:I ry <br />"� b <br />PHONE #1 ExT <br />t'�A R 521 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Wt.f1YK Lni Gc 1CHECK If BILLING ADDRESS <br />BUSINESS NAME I <br />PHONE #_?_ EXT. <br />HOME or MAILING ADDRESS I <br />FAX # ) <br />CITY STATE CP 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 w to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard AT and Fy_ED//�xAL law . p <br />APPLICANT'S SIGNATURE: DATE: I V ZZ d <br />PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required 77ur <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 environmentallsite assessment , information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon a5 It IS available and at the Same time It Is p�gtp¢d 10 me or <br />my representative. �l /•A./I <br />TYPE OF SERVICE REQUESTED: -Ii;)O Z'iVVI(r <br />`�S vI VV' <br />r/V <br />COMMENTS: <br />UL, <br />�rh pEp�Hr�'TY <br />SENT <br />ACCEPTED BY: ,/1 /I ,/t J <br />EMPLOYEE#: <br />DATE: 22�� <br />ASSIGNED TO: L(n pli�S <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: W152- � <br />Amount Pa' <br />/sa 6 <br />Payment Date <br />Payment Type C�.6 <br />Invoice# <br />Check# <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />