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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECKNBILLING ADDRESS <br />CHECK <br />FACILITY ID # <br />j"i; 0o0 --T 19 <br />SERVICE REQUESTT # <br />a: <br />OWNER i OPERATOR ^ 'T <br />J�v CHECK If BILLING ADDRESSQ <br />FACILITY NAME l /,Z tA <br />?1'7-7 <br />FAX # <br />( I <br />CITY <br />SITE ADDRESS 3 rr/v-I <br />Street Number <br />Direction <br />�(_y p <br />Street Name <br />CI <br />EMPLOYEE III: <br />95-376 <br />ZI C De <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Straal Number <br />Street Name <br />SERVICE CODE: O b <br />CITY <br />STATE ZIP <br />Amount Pai <br />PHONE #1 EXr- <br />(31 til 2�n .i6 g v <br />APN # <br />Payment Type JSa <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />� <br />BOS DISTRICT <br />LOCATION CODE <br />sc+.,t o," , � CONTRACTOR / SERVICE REQUESTOR <br />REQUES R <br />'r <br />7777 I <br />CHECKNBILLING ADDRESS <br />CHECK <br />BUSINESS NAME t,. <br />COMMENTS: <br />C�.�A �c C�� Z7�. <br />`nJ •J <br />pjt!El EXT. <br />HOME or MAILING ADDRESS <br />3D D 7 R6 <br />ACCEPTED BY: <br />�� ('e <br />FAX # <br />( I <br />CITY <br />n <br />STAT EA AP 1 /r <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMr:NTAI. HEALTtt DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this)qyRfication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard , rr and FI"cUERAL laws. /t� r7 <br />APPLICANT'S SIGNATURE: DATE:T y3,/2 / /2,0 2 Z <br />PROPERTVl BmSINF_%S011'NERI9A OPERn7oR/l4rAGER ❑ OTHER At TIIORIZED AGENT❑ <br />Jf APPLICANT is not the B11.1.1 \(, PAKT)'. proof if authorization 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 t0 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 />^I / <br />COMMENTS: <br />C�.�A �c C�� Z7�. <br />`nJ •J <br />u/VFX <br />MAR28 <br />NFq T�OFtMVCou", Y <br />ACCEPTED BY: <br />�� ('e <br />EMPLOYEE #: <br />DATE: <br />ASslGNEDTO: <br />EMPLOYEE III: <br />DATE: 3_ 2 <br />JP <br />Date Service Completed (if already completed): <br />SERVICE CODE: O b <br />IE: �CO2 <br />Fee Amount: 5 2 <br />Amount Pai <br />I b(D <br />Payment Date Z <br />Payment Type JSa <br />Invoice # <br />Check # / */ g <br />� <br />Recei ed By: <br />EHD 48-02-025 <br />REVISED 111172003 <br />l ` - 50W1 5' l5' <br />SR FORM (Golden Rod <br />