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%k <br />SAN JOA UL, _ OUNTY ENVIRONMENTAL ONMENTAL HEALTH �r;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />1 CHECK If BILLING ADDRESS <br />\ J�Ci <br />C� <br />SERVICE REQUEST # <br />7N90Ar'r\P-r\\ %/yL" <br />PHONE # Ear. <br />3 2y3 <br />£GIG a <br />S 4o060 2-10 <br />OWNER/ OPERATOR <br />FAX# <br />1 Q C <br />CHECK If BILLING ADDRESS <br />FACILITY NAME G <br />�kE. <br />SSgE ZIPQ Z <br />ACCEPTEDBY: .�` ./J <br />LLQ <br />(A ,0 r <br />EMPLOYEE#: /� 9 <br />6/�J21a <br />DATE: <br />SITE ADDRESS <br />ASSIGNED TO: T,,t <br />Web} "[Qfy�Ira£ �� <br />EMPLOYEE #: <br />'`(QCY <br />'1s n� <br />q50 <br />SERVICE CODE: J L2 <br />PIE: <br />--/— <br />Fee Amount: . 0 0-,) <br />Street NumberDireatlo <br />Payment Date <br />Street Name <br />Payment Type <br />CIN <br />Zip Cod. <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Received By. <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 En. <br />APN # <br />LAND USE APPLICATION # <br />U09) 26-1- 1(o31 <br />32- tq7 d -o / <br />PHONE #2 Eur. <br />BOS DISTRICT <br />5 <br />LOCATION CODE <br />( ) <br />3 <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />S qty LC <br />1 CHECK If BILLING ADDRESS <br />\ J�Ci <br />C� <br />BUSINESS NAME <br />PHONE # Ear. <br />£GIG a <br />Ic, f1$ ^ \ <br />HOME o—r7MAILING ADDRESS <br />FAX# <br />1 Q C <br />( ) <br />CITY <br />SSgE ZIPQ Z <br />i <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 />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�----� DATE.:: CO <br />PROPERTY/ BUSINESS OWNER❑ NJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT COA6ll 'I' v t� <br />IfAPPLICANT is not the BYLLING 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 <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 />COMMENTS: Cj'CG <br />JUN 14 LWO <br />ENVIRONNIENiT HEALTH <br />ACCEPTEDBY: .�` ./J <br />LLQ <br />EMPLOYEE#: /� 9 <br />6/�J21a <br />DATE: <br />/ /Q <br />ASSIGNED TO: T,,t <br />EMPLOYEE #: <br />DATE: <br />/37&c <br />Date Service Completed (if already completed): <br />SERVICE CODE: J L2 <br />PIE: <br />--/— <br />Fee Amount: . 0 0-,) <br />1 Amount Paid 59,3c). O C) <br />Payment Date <br />I-0 <br />Payment Type <br />Invoice # <br />Check #a, <br />Received By. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />