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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />BUSINESS NAME I <br />ERVICE REQUEST # <br />00 ?597-74-7 <br />OWNER / OPERATOR <br />t ! <br />G <br />CHECK if BILLING ADDRESS <br />HOME Or MAILING ADQRESS <br />FAX# <br />It <br />( I <br />FACILITY NAME <br />� <br />$ITEADD � SS <br />ACCEPTED BY: <br />LVI, <br />V l ' q <br />� <br />J JJ <br />Street Number <br />Dlrectlon <br />trees Name <br />City <br />y <br />ZID Code <br />HOME or MAILING ADDRESS (If Different froSite Address) <br />Date Service Completed (if already complete ): <br />SERVICE CODE:VO <br />S11 li cho, <br />111 J X- <br />T <br />Street Number <br />`y O <br />Street Name <br />CITY <br />Payment Date <br />512-42-4 <br />STATE ZIP <br />C &' i S S a <br />PHONE#1 <br />ExT <br />APN # <br />Received By: <br />LAND USE APPLICATION # <br />(209) So 22 <br />ny <br />PHONE#2 <br />Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />IT <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME I <br />PHONE # EXT. <br />t ! <br />G <br />am <br />gQU <br />HOME Or MAILING ADQRESS <br />FAX# <br />It <br />( I <br />CITY STATE 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 <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 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 />SIGNATURE: <br />DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHOR1zED AGENT❑ <br />IfAPPLicANT is not the BILL/NG PARTY proof of authorization t0 sign is required <br />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 environment site assessment <br />information t0 the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a[ � it Is <br />provided to me or my representative. �/�i�,_ _ <br />TYPE OF SERVICE REQUESTED:vim <br />COMMENTS: <br />ei <br />102, <br />am <br />gQU <br />vy <br />RIliCNpEry� <br />ACCEPTED BY: <br />V l ' q <br />S. <br />EMPLOYEE #: (/r �c/'S <br />1 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: �Vj( <br />DATE: Z <br />q <br />!� <br />Date Service Completed (if already complete ): <br />SERVICE CODE:VO <br />' <br />P I E: l <br />Fee Amount: <br />`y O <br />Amount Paid <br />— <br />Payment Date <br />512-42-4 <br />Payment TypeInvoice <br /># <br />Check # <br />Received By: <br />EHD 48-02-025 ��`7 lW l ` W SR FORM (Golden Rod) <br />REVISED 11/17/2003 ^ <br />