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SAN JOAQUJhr COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property LL <br />HCl'//Vev-)7s <br />BUSINESS NAME ,F <br />l� G <br />FACILITY ID # <br />TSNo0c�0 <br />HOME or MAILING ADDRESS <br />ft <br />SERVICE REQUEST #lql, <br />S)2oo- I �d'i <br />OWNER / OPERATOR <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />stmee Number <br />DI o <br />u�' ,"/(W <br />9treat Na <br />SERVICE CODE: <br />Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Steel Number <br />Payment Date <br />Stmet Nme <br />CITY <br />STATE <br />ZIP <br />PHONEM Em <br />(z��> 3&19-Lq <br />APN# L k ^ <br />i <br />LAND USE APPLICATION# <br />PHONE #2 Em. <br />( 1 <br />BOB DISTRICT <br />opt <br />LOCtA�TIQN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR // � /f /"& / er./ ` T�J� CHECK N BILLING ADDRESS <br />(� /` <br />BUSINESS NAME ,F <br />l� G <br /># <br />PHONE�' <br />E78/ _ D <br />HOME or MAILING ADDRESS <br />ft <br />FAA# <br />( ) '78/- D <br />CITY D C U/ /n STATE ZIP �5& 7S <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 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: ". (�(/L(�.L.Cf/y%DATE: ✓ v2�/� /1 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER [3 OTHER n <br />ER AUTROzED AGENT 10 _(�� / " (� i <br />If APPLICANT is not the BILLING PAR rrproof ofauthorization tosign isrequired rule <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 />O`J aiv- I <br />,(1,(—I/vt0 <br />COMMENTS: <br />S�r/lo fPr Safe/ /,,,74e oee9Dv S . <br />fh rn�r/yrs, bra./s, Nj <br />(3) Cozier Pcv <br />ACCEPTED BY: U-.�r� ` • <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: •i�S H�"'V1 <br />EMPLOYEE#: <br />DATE: 0JO 0.0N <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />PIE: b <br />Fee Amount: 2 jpp <br />Amount Paid �� . �'� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 6,1 Z� <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />W <br />pU� <br />p�NI <br />SME <br />