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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST I C� <br />Type of Business or Property <br />FACILITY <br />ID <br /># <br />lklk <br />, <br />SERVICE REQUEST # <br />\ 1 <br />s�n',,oAQ 4?0 <br />CHECK if BILLING ADDRESS <br />y <br />flfpopMFAt <br />BUSINESS NAMEPHO <br />C' L06,s`� <br />" <br />E <br />��. <br />ExT. <br />a� 6 <br />OWNER/ OPERATOR <br />` <br />�� <br />.�,�� <br />#: <br />CHECK if BILLING ADDRESS ❑ <br />ASSIGNED TO: <br />YY\ p J 1 <br />ADDRESS <br />#: <br />DATE: <br />FAX# <br />SERVICE CODES "—'��� <br />P / E: Q L <br />Fee Amount. � <br />FACILITY NAME <br />/S CJl <br />CITY <br />1%\/\kti.v <br />( <br />Invoice # <br />STATE <br />ZIP <br />\- <br />, <br />SITE ADDRESS <br />C L S}_ <br />� <br />2� Street Number <br />Direction <br />Street Name <br />Cit <br />Cod <br />ZinCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />2°J ( I S ^^ +2 c J� <br />J Street Number <br />Street Name <br />CITY <br />�C-A Vhv-<�C c� <br />STATE q ZIP <br />PHONE #1 <br />ExT. <br />APN # <br />LAND <br />USE APPLICATION # <br />< �1 l <br />PHONE #2 <br />ExT. <br />BOS <br />DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />CF <br />COMMENTS: <br />lklk <br />, <br />P'ya, ,,__ <br />\ 1 <br />s�n',,oAQ 4?0 <br />CHECK if BILLING ADDRESS <br />y <br />flfpopMFAt <br />BUSINESS NAMEPHO <br />C' L06,s`� <br />" <br />E <br />��. <br />ExT. <br />a� 6 <br />ACCEPTED BY: <br />.�,�� <br />#: <br />( <br />ASSIGNED TO: <br />HOME Or MAILING <br />ADDRESS <br />#: <br />DATE: <br />FAX# <br />SERVICE CODES "—'��� <br />P / E: Q L <br />Fee Amount. � <br />Amount Paid <br />/S CJl <br />CITY <br />1%\/\kti.v <br />( <br />Invoice # <br />STATE <br />ZIP <br />\- <br />, <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also cert <br />ify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordina>�ce Codes, 1EDERAL laws. <br />APPLICANT'S SIGNATURE. C` C� DATE: (� , Z�' <br />00� <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br />APPLICANT is not the BILLING PARTY, proof of authorization tosigngi <br />If <br />s 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 Al <br />environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and ate same time it is <br />provided to me or my representative. w :'Iww)PAJO� <br />114 <br />TYPE OF SERVICE REQUESTED: <br />CF <br />COMMENTS: <br />lklk <br />, <br />s�n',,oAQ 4?0 <br />y <br />flfpopMFAt <br />" <br />FHT <br />ACCEPTED BY: <br />EMPLOYEE <br />#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE <br />#: <br />DATE: <br />Date Service Co pleted (if already completed): <br />SERVICE CODES "—'��� <br />P / E: Q L <br />Fee Amount. � <br />Amount Paid <br />/S CJl <br />Payment Date 2� <br />Payment Type t <br />Invoice # <br />Check # <br />5� <br />Rece' ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />