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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />SERVICE RE�U ST # <br />FAX# <br />CITY STATE /? ZIP ( .� <br />EMPLOYEE #: <br />00 <br />OWNER PERATOR <br />CHECK If BILLING ADDRESS ❑ <br />b <br />Amount Paid <br />FACILITY NAME <br />Payment Date I& �22/ <br />Payment Type <br />SITE ADDRESS <br />Check # <br />� ` <br />V` �1 <br />�eQ m D <br />�✓� <br />tr <br />Seet m <br />Direction <br />t e <br />treea <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />re <br />is I 0 <br />Street NumberF <br />1�/� <br />/1a – m re9 ame <br />CITYA c^ <br />S SATE ZIP �� D <br />S <br />l'� O <br />R <br />PHONE #1 E'. <br />(�o9) gy " <br />APN # <br />���0s�y - <br />LAND USE APPLICATION # <br />F -a ��0030 <br />PHONE #2 EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />C <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LC' V'P N J 1 <br />l { l l I CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Ex -r. <br />HOME or MAILING ADDRESS } j <br />FAX# <br />CITY STATE /? 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. /� �✓ h I <br />APPLICANT'S SIGNATURE: G,=�o L-� DATE: } 0 <br />PROPERTY / BUSINESS OWNERI OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ P <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Titleier <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper loca`tt`'Avcq� <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental a3achssmeent <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and 9,Qe same tffl48'?, <br />provided to me or my representative. 7 ENS gQ.tN C <br />TYPE OF SERVICE REQUESTED: Vr� { j �� ��' b! ? 17 yin r P4( l� li�Jd TyQFp�NTq� <br />COMMENTS: '`„S <. 1 -SU I 1�? Le 5� -. / 6, I ") v'?rJ <br />Cf'e;,���/ c;i,r�1 i✓1�� InteJYiY}/ 6{ ,sell c�7oil <br />rl; e P 1 �i� s / n� p '[Die- j l/'I P i CALL(209)953 <br />FOR INSPECTIC <br />24-HOUR NOTI <br />REQUIRED. <br />ACCEPTED BY: ��^ /� <br />EMPLOYEE #: <br />DATE: 7Q S" I <br />ASSIGNED TO: <br />EMPLOYEE #: <br />j <br />DATE: 11 ?2—,; <br />Date Service Completed (if already completed): <br />SERVICE CODE:3 u l P 1 E: o ' 1 <br />Fee Amount: $ <br />Amount Paid <br />Payment Date I& �22/ <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />-7697 <br />N. <br />CE <br />