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SAN JOAQUI DUNTY ENVIRONMENTAL HEALTH i .'ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />3//7 <br />CHECK it BILLING ADDRESS <br />SERVICE REQUEST # <br />s� �r9 <br />OWNER/ OPERATOR <br />EMPLOYEE#: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />b <br />DDRES <br />DATE: <br />SITE�ADDDRESSq,I�y�.yy� <br />�7 Stre¢t Numher <br />Direction <br />ej%lf <br />Sfreet tlSme <br />( ) �- <br />Y <br />� Cll <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />� <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EaT. <br />API # <br />LAND USE APPLICATION # <br />PHONE #2 Er, <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />14-1d AlIal <br />CHECK it BILLING ADDRESS <br />BUSINESS NAME <br />'q <br />w / <br />EMPLOYEE#: <br />PH NE# <br />HOMEorD IN <br />DDRES <br />DATE: <br />FAX If <br />l <br />( ) �- <br />CITY <br />�2 J <br />STATE ZIP <br />G <br />� <br />Check # 52D 7 <br />BILLING ACKNOWLEDdEMENT: 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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUW <br />COUNTY Ordinance Codes, Standards, E a FEDERAL laws. <br />APPLICANT'S SIGNA177 TU ` DATE: <br />PWPER 1) BUSINESS OWNER OPERATOR/MANAGER OTHER A UTHORIZED AGENT <br />/f.APpL1C is nor rhe erzuNc Pnk7v proof of authorization to sign is requires! Tule <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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 />�uT <br />TYPE OF SERVICE REQUESTED: <br />P A,y m=n a <br />NED <br />COMMENTS: <br />w aa0++ <br />JUL b L 11 <br />OUNW <br />SANDNMC <br />ENVIRvtewH DEPARTwENf <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />J <br />ASSIGNED TO: �/{ <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: 5'7 ) <br />Fee Amount: �� �� <br />Amount Paid <br />�2 J <br />Payment Date <br />Payment Type l/ <br />Invoice # <br />Check # 52D 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />