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SAN JOAQUnN COUNTY ENVIRONMENTAL HEALTH —_.'ARTMENT <br />SERVICE REQUEST <br />Ty of Business or Property <br />FACILITY ID # <br />SERVICE REQUESTIf <br />S2oo-7 9 1'5 <br />OWNER I OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �p,A ( T„ /rc <br />y5 t.�`EtD C_ <br />/1 <br />i,�T <br />LL <br />SITE D ESS <br />Street Number <br />Drection <br />tre¢t Name <br />CITY Sd.. � <br />L© <br />Ci <br />��LL <br />ZI Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />sheet Numbar <br />Sheet Name <br />CITY <br />PIE:. <br />STATE ZIP <br />PHONE#1EXT' <br />P <br />APN# <br />Payment Date <br />LAND USE APPLICATION# <br />PHONE #2 EXT. <br />( ) <br />Invoice# <br />BOS DISTRICT , <br />�_•II <br />LOCATION CODE <br />QOM\ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 'fin �nC `��e// <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME �S�.n ___,. <br />DO© % %{/q//1 j <br />/r�y�-( J C rl <br />P E <br />�%�.� / �(� EXT <br />PQ�QQ <br />HOMEor MA NGA DRESS <br />LL <br />EMPLOYEE #: <br />�9��/ <br />T� <br />--4'? <br />CITY Sd.. � <br />EMPLOYEE#: <br />STATEe <br />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 or <br />activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will a done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />��/ <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER El OTHER AUTHORIZED AGENYLI <br />If APPLICANT is not the BILLING PARTY, 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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment n <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is prov� �1�AI� <br />my representative. ,,•• <br />Q <br />TYPE OF SERVICE REQUESTED: <br />AN: <br />COMMENTS: <br />SANjOAQ <br />14 1110%fI CO3 <br />F <br />ACCEPTED BY: ?. <br />✓I <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />-Z— <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:-�-� <br />PIE:. <br />Fee Amount:Amount <br />P <br />3�j <br />Payment Date <br />- <br />PaymentType i,56� <br />Invoice# <br />C ck# 4762 <br />Receiv dBy: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07117/08 <br />18 <br />I� <br />