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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# Em <br />FACILITY ID # <br />SERVICE REQUEST # <br />CITY STATE ZIP <br />DF q�NT�O?iY <br />OWNER/ OPERATOR <br />ACCEPTED BY: <br />/ <br />C��I _ \ <br />1.1i ✓� \ <br />I I <br />CHECK If BILLING ADDRESS <br />FACILITYAME <br />5 Cin <br />Cie'-- FS� t3W <br />SERVICE CODE: ob 1 <br />PIE: <br />-l- e <br />V I <br />SITE ADDRESS <br />col \ <br />l`� ` <br />Check # <br />-Tt��C , <br />cl5 3 9- <br />Street Numher <br />Direction <br />Street Name <br />C <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />\-4 12 - <br />2Street <br />Site Number <br />Street Name <br />CITY` <br />TE ZIP <br />� c '3V"� S z e <br />PHONE#1�^ <br />(2M) -7q V <SI <br />ELT• <br />V3 <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 <br />( ) <br />EX . <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR f <br />Cl--� r7 �_ �t� ,� � CHECK If BILLING ADDRE55O <br />��-{ '�J OV V �- <br />BUSINESS NAME <br />PHONE# Em <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <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 on this form. <br />I also certify that I have prepared this ap I t tha the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE E laws. (' <br />APPLICANT'S SIGNATURE: DATE: I2 I <br />PROPERTY/ BUSINESS OWNER❑ A� AGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPL/CANT is not the BILLINGPARTY }goof 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: r` R <br />COMMENTS: <br />Mpt Fo <br />8 <br />DF q�NT�O?iY <br />Ml <br />ACCEPTED BY: <br />/ <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: Ci� ✓1� / <br />EMPLOYEE #: S <br />DATE: I I $ I <br />Date Service Completed (if already completed): <br />SERVICE CODE: ob 1 <br />PIE: <br />Fee Amount:�'Ql <br />Amount P ' <br />a d� <br />Payment Date S 2 - <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 />i So <br />5 <br />