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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />REQUEST # <br />PHONE# ExT, <br />Q <br />-I n�2�►�11 <br />/SERVICE <br />SI°C QO$�l�l� <br />OWNER / OPERATOR 'a <br />S <br />0 f V .J <br />CHECK if ADDRES <br />Z-+ o( <br />V <br />T FACILITYN � <br />ASSIGNED TO: <br />s M <br />EMPLOYEE#: <br />"SITE ADDRESS, <br />DATE: <br />Date Service Completed (if already completed): <br />`1 l _ Jl,yl <br />V9G0 VR <br />(>T5o?-IG <br />V <br />eetNdrhbf/ <br />Diredbn <br />.- <br />, <br />Street Name <br />Cit'�UYt <br />ZI Code <br />`ROME or AILINGA <br />DRESS (If Different from Site Address) <br />Received By: <br />LIr <br />P/ <br />Street Number <br />Street Name <br />CITY r G� <br />S TE ZIP <br />PHONE #1 l E..APN <br /># <br />LAND USE APPLICATION # <br />9p? I �D <br />PHONE#Z EzT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />'REQUESTOR .I <br />CHECK If BILLING ADDRESS <br />(BUSINESS NAMEJ <br />r; L 5 .. �1 <br />J i t <br />PHONE# ExT, <br />CFIOME or MAILING ADDRESS <br />476 n✓►e 1 &( <br />FAz # <br />) <br />`CITYC �G� T E 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 <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 />A_PPLICANT'S SIGNATURE:e 69 nu p L e 2 DATE: <br />PROPERTY/ BUSINESSOWNER❑ OPERATOR /'MANAGER ❑ OTHER AUTHORIZED AGENT 11 <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 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: ' W V -PP, <br />l yts e <br />COMMENTS: <br />�Q <br />AEC 2071 <br />4NN pE MFNTiqN1Y <br />,I 1 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: I Z I <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 100 <br />PIE: I U <br />Fee Amount: rpi5-z — <br />Amount Paid <br />.- <br />, <br />Payment Date I2 b <br />Payment TypeInvoice <br /># <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />�( 61051 S' <br />