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Iii SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />Fti's 0 6[0(1 <br />SERVICE REQUEST # <br />5R <br />OWNERIOPERATOR /,a p <br />G LL O I, . <br />` l Q I I CHECK If BILLING ADDRESS <br />FACILITY NAME I ,- v { yt , VIA <br />C r n <br />fe <br />SITE ADDRESS I�l2l �I. <br />Slreel Number <br />Directlon <br />^ V) ron l C <br />/ V Street Name <br />Cit <br />ASSIGNED TO: <br />Zip Code J <br />HOME or MAILING ADDRESS (If Different from Site Address) I—�Z; 7 <br />Street Number <br />/'� �,/(�K) � o n <br />lJ `S'treat�Name <br />ft_ _ e <br />"_`J <br />CITY � ,^ , <br />STATE CAZIP <br />(�J <br />PHONE#1 IEa1 <br />Fee Amount: ( Z <br />APN # <br />LAND USE APPLICATION # <br />Payment Date <br />PHONE #2 FK . <br />( ) <br />Payment Type V <br />AIIevI <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQ <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE #T• <br />HOME or MAILING ADDRESS <br />FAX# <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNO GEMENT: 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 />APPLICANT'S SIGNATURE: 4 (f2 — DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ 4ANAGER ❑ OTHER AUTHORIZED AGENT 1:1 <br />If APPLICANT is not the BILLING 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 ,I/ted' yryS sment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available analllk ki [e it Is <br />provided to me or my representative. QFCENED <br />TYPE OF SERVICE REQUESTED: <br />2 9 2091 <br />COMMENTS: <br />MAR <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HMTH DEPARTMENT <br />ACCEPTED BY: <br />W <br />EMPLOYEE M <br />DATE: <br />2. 2 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />1. 1SERVICE <br />CODE: <br />P I E: 1 <br />Fee Amount: ( Z <br />Amount Paid <br />S 2 <br />Payment Date <br />Payment Type V <br />AIIevI <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 OQ „��r„��(/ <br />5 <br />