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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Pit 0 S u-=� 39 g <br />Type of Business or Property <br />BUSINESS NAMEtt�f,, n <br />V� L <br />FACILITY ID # <br />SERVICE REQUEST # <br />FD a OL -FM i I -e V` <br />CITY _ G... STATE ZIP <br />t' Pr o o 2 b9 u `{ <br />SoQ ODS L4 4` 0 <br />OrR,1 C>�� A� <br />/`J I U <br />` !�� <br />iv <br />CHECK if BILLING ADDRESS <br />FACILITY NAME }Z !a � <br />1..�\ <br />`a � ( e <br />U <br />ACCEPTED BY: <br />SITE ADDRESS <br />EMPLOYEE <br />#: <br />^ <br />G G <br />/ v <br />%SZId� <br />Street Number <br />Direction <br />Date Service Completed (if already completed): <br />�u ��( il <br />treat Name <br />CR y <br />21 Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Date S <br />Payment Type A <br />Invoice # <br />Street Number <br />Street Name <br />CIT,)' 2 Y1 <br />STATE Zip �S <br />64 <br />PHONE A <br />En. <br />APN # <br />LAND USE APPLICATION # <br />(S(0 )'J-06 /c/%2 <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />OCATION CODE <br />� <br />-HL <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEtt�f,, n <br />V� L <br />PHONE# Ezr. <br />HOME or MAILING ADDRESS <br />li%i <br />FAX # <br />( ) <br />CITY _ G... 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 ap ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TAT and FEDERAL)"s. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUs1NESs OWNER❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT El <br />If APPLICANT is not the BILLING PAR TP 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: fi D Plavi C Y wYIVI <br />COMMENTS: , 1„ ^ �LAc� ��i �� <br />� <br />NLPAE <br />�V�D <br />OV 05 <br />N / ?021 <br />EN�gQU4YC <br />OIJ <br />H�ACr/ RpE TN 7-y <br />T <br />ACCEPTED BY: <br />EMPLOYEE <br />#: <br />DATE: I I C <br />J <br />ASSIGNEDTO: <br />EMPLOYEE#: <br />07 ('7 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: SC 5 a3 <br />PIE: 1 Cv 0 1 <br />Fee Amount: .A 4,r)� <br />Amount Pai T�(o OT <br />Payment Date S <br />Payment Type A <br />Invoice # <br />Check #C l/3 2Z6 ✓ ! <br />Received By: <br />L <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />