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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />:: <br />FACILITY ID # <br />SERVICE REQUEST # <br />Z74M T&Z6A <br />FAx# <br />CITY !G.1- / _� E ZIP <br />OWNER i O ERATOR <br />76�) <br />CHECK If BILLING ADDRESS <br />mmDo C•/C.l <br />I�- <br />EMPLOYEE M <br />FACILITY NAME�� 44, <br />R-z:ywiyPQ <br />er a. <br />L6 AW <br />SITE ADDRESS <br />I <br />P I E:I �Q <br />Fee Amount: 1 QU <br />lY <br />- <br />Payment Date <br />Street Number <br />DirectionLeet <br />Invoice # <br />Name <br />city <br />ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />G <br />Street Number <br />Street Name <br />CITY <br />aSTA� <br />ZIP t�SZ1 <br />o <br />1 �d <br />PHONE #1 EXT_ <br />APN # <br />LAND USE APPLICATION # <br />( p / <br />PExr. <br />I= �ISZ g3 Z <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUES R <br />F,vurV ID J ^ CHECK If BILLING ADDRESS E] <br />BUSINESS NAME - <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAx# <br />CITY !G.1- / _� E ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 <br />or 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 th the wo o be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED AL law . <br />APPLICANT'S SIGNATURE: e DATE: 671—,f'0— 0.,020 <br />PROPERTY/ BUSINESS OWNERJU PERATOR/MANAGER IER AUTHORIZED AGENT❑ <br />If APPL/CANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L 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 />�X <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: % <br />DATE: q ?D n� <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: 9? 2.V <br />Date Service Completed (if already completed): <br />SERVICECODE: CJ��7 <br />P I E:I �Q <br />Fee Amount: 1 QU <br />lY <br />Amount Paid 41 u <br />Payment Date <br />o o <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 />