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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME <br />SERVICE R,(EQU"EESjT�# <br />_ <br />PHONE#EXT. <br />4ltJi� �v'Z <br />HOME or MAILING ADDRESS p <br />©1 <br />1~ 1 0 -Cx� -� <br />STATE C.pp, ZIP 4 <br />CALL (209) 953-7697 2 <br />V <br />OWNER/ OPERATOR <br />CHECK If BILLING ADDRESS <br />i2 IJ5 A L �� I'� <br />(� <br />24-HOUR NOTICEN <br />FACILITY NAME <br />ACCEPTED BY: / �, <br />SITE ADDRESS <br />EMPLOYEE #' DATE: 1? � % <br />�L Lj-1 t� VL Va'W <br />U <br />Date Service Completed (if already Completed): <br />1-11" -1 Street Number <br />Direction <br />Street Name <br />Fee Amount: <br />(� <br />Clt <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Date 12- <br />Payment <br />Payment Type <br />e6) � 'W "'-I y `� 1 ( ` C Street Number <br />Check # 2 ZJ <br />Street Name <br />CITY L <br />c� w•7 C 1'�r <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(qlO 53) <br />0 oe0'�b <br />- 00) <br />PHONE #2 EXT. <br />(LII�) 1 3 1 (,-1 ru <br />--] <br />BOS DISTRICT <br />y <br />LOCATION CODE <br />q q <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR J n_^ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />�l�r>2 <br />_ <br />PHONE#EXT. <br />4ltJi� �v'Z <br />HOME or MAILING ADDRESS p <br />FAX # <br />CITY <br />STATE C.pp, ZIP 4 <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 />APPLICANT'S SIGNATURE: DATE: �14z 7/Z 1 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information t0 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: Ver ( f <br />( -,,j1 n e,: T► J!'1 '6 f <br />p eP 4 S}, -U L JL; f e -�o .5e�I C S 1, <br />COMMENTS: <br />�l�r>2 <br />F <br />CALL (209) 953-7697 2 <br />FOR INSPECTION. <br />JO <br />24-HOUR NOTICEN <br />ENS/ROIJ/NCO <br />ACCEPTED BY: / �, <br />REQUIRED. <br />EMPLOYEE #' DATE: 1? � % <br />ASSIGNED TO: 6`7 <br />#: DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P / E: I l7oi <br />Fee Amount: <br />Amount Paid <br />a <br />Payment Date 12- <br />Payment <br />Payment Type <br />Invoice # <br />Check # 2 ZJ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />