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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST # <br />CHECK If BILLING ADDRESS <br />CAMt <br />biz os6 <br />OWNER 1 OPERATOR <br />BUSINESS NAME <br />CHECK if <br />PHONE# <br />EXT. <br />BILLING ADDRESS <br />FACILITY NAME <br />tt <br />ACCEPTED BY: <br />EMPLOYEE #: <br />SITE ADDRESS <br />e <br />�-�t' �.>c\C l k"(c ('k CI <br />EMPLOYEE #: <br />�-cx <br />Street Number <br />Direction <br />rest Name <br />STATE <br />city <br />e <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Check # ?—'?I D <br />"T'. <br />l : c7 <br />Street Number <br />Street NaMe <br />CITY t <br />SATE ZIP <br />"-,T� _�� ` Ir. <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />y <br />w <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE UESTOR <br />r-- / <br />PAYM E <br />CHECK If BILLING ADDRESS <br />/� 7 <br />14' h2loav grovnt( S'K✓Laet , Mach well Aad �,3/l—S.xL ctnA one L Sa %e �tf�n. <br />62cKiill frek �f3-3 <br />FEB 2 0 2 <br />BUSINESS NAME <br />PHONE# <br />EXT. <br />F0I(C'W �jCcluo�QS G'rL ICS° 5 rk J6ar$ l.ac{ i cl �� r'�Zri/a2i1V`�• <br />o <br />HEALTH DEPART <br />ACCEPTED BY: <br />EMPLOYEE #: <br />HOME or MAILING ADDRESS <br />FAX# <br />EMPLOYEE #: <br />DATE; <br />Date Service Completed (If already completed): L-) /6) Cy <br />SERVICE CODE; <br />CITY <br />1 7 <br />STATE <br />ZIP Q <br />� c <br />I <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 l 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 laws. <br />APPLICANT'S SIGNATURE. v F r DATE: 1(, t k�u <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / M NAGER ❑ OTHER RUTH ZED AGENTx-V a Pl23i Cit' Ia <br />If APPLICANT is not the BILLING PART}' 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: <br />PAYM E <br />/-514,1 <br />/ <br />COMMENTS: Sta,✓f iZ fla-A �ivtlSN J )1 iqm , roG i wellI b3 lot" h- prcb.e t rttt cbI- ra <br />Ee, IV <br />14' h2loav grovnt( S'K✓Laet , Mach well Aad �,3/l—S.xL ctnA one L Sa %e �tf�n. <br />62cKiill frek �f3-3 <br />FEB 2 0 2 <br />Ltitl�T -fkli roe.rrtla&,d CewleAt• Weal labcleCI -l-, � etnA <br />9-14 level <br />8-1' water I cvv ✓ r pu✓• je �J� G� !l0 (Conpie, • CkviLn, CA l-u5tCcty <br />SAN <br />IME <br />F0I(C'W �jCcluo�QS G'rL ICS° 5 rk J6ar$ l.ac{ i cl �� r'�Zri/a2i1V`�• <br />o <br />HEALTH DEPART <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE; <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE; <br />Date Service Completed (If already completed): L-) /6) Cy <br />SERVICE CODE; <br />P 1 E: <br />Fee Amount: " <br />Amount Paid tF 0 C7 <br />Payment Date Z o D <br />Payment Type <br />Invoice # <br />Check # ?—'?I D <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />T <br />D <br />109 <br />1UNTY <br />-AL <br />DENT <br />