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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />n C <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />t -'A' )gel0 <br />SERVICE REQUEST # <br />YS �s 1 <br />OWNER/OPERATOR <br />,^�\^ \� <br />( \t, l� <br />$-,\` ) Q <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME �Tf- <br />\(�\ <br />^ n,�'� <br />llv <br />('� <br />U 'G... �'W c <br />Date Service Completed (if already Completed): <br />SITE ADDRESS l r� <br />1 tr(e7ae Number <br />Dinaalga <br />� � <br />tree a �� <br />� � <br />Amount Paid«a <br />I Kk� <br />l7 �� <br />/ <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />STATE <br />zip <br />PHONE#1 EXT. <br />( ) <br />APN# <br />LAND USE APPLICATION# <br />PHONE #2 EXT <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I \ <br />n C <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEI <br />n <br />t fJ; JILL. `�O(� <br />(7 <br />P # <br />[� _ 1�11 EZT <br />HOME Or MAILING ADDRESS /`l� <br />SOCA <br />Jv <br />DATE: <br />Date Service Completed (if already Completed): <br />FAx# <br />( ) <br />CITY <br />zlp <br />STATE(LiI4 <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 accordanc with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, <br />.&'I'PiTE an FEDERAL la s. O rI� <br />APPLICANT'S SIGNATURE: DATE; �/ 0 O <br />PROPERTY/ BUSINESS OWN ER 11 OPERATOR/AGER OTHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PARTY iu f of a orization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: <br />MEN <br />COMMENTS: <br />-wep-�u Mpg 12Ea <br />✓ 2�za, G/�. 5/ i4 . w�� a�u s"c rx r ® stwrOA 20?0 <br />vim. Nrti. M ON ° rr <br />sU <br />ACCEPTED BY: 1 . �O.n/1 <br />EMPLOYEE #: <br />DATE: 'Z� 2c), <br />ASSIGNED TO: J�' V Cl J <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />PIE: .2 <br />Fee Amount: `S Z•_ <br />Amount Paid«a <br />� <br />Payment Date <br />LO <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />L! <br />SR FORM (Golden Rod) <br />