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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 REQUEST # <br />FAX# <br />CITY STATE ZIP <br />DATE: / 21 <br />sR o73�-77 <br />OWNER / OPERATOR \ <br />EMPLOYEE#: g <br />DATE: <br />Date Service Completed (if alt <br />y completed): <br />SERVICE CODE: 2 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME / <br />�/ <br />Amount PaidkpI <br />a �� <br />Payment Date <br />(PZ912- <br />SITE ADDRESS 2,�\�-L <br />L <br />I <br />�� JR \/ `ZaC�—c�. <br />I <br />�C <br />���`�l <br />c� <br />/ S3 2,:.) <br />Street Number <br />Direction <br />et Name <br />CN <br />?iP Cotle <br />HOME or `MAILING ADDRESS (If Different from <br />Site Address) <br />Va \ <br />_ <br />SV <br />1 �`O V <br />Street Number <br />[Name <br />CITY-S- <br />C�I�� <br />E <br />C TATE <br />�2>2U <br />PHONE#t�t <br />LAND USE APPLICATION# <br />(2c)l la'I_�2 <br />r6L <br />PHONE#1 ��� _ <br />BOS DISTRICT <br />LOCATON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, <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 />1 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, S" TE and FEDERAL IawS. <br />APPLICANT'S SIGNATURE p DATE: (a <br />PROPERTY/ BUSINESS OWNER0— PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />ffAPPLICANT is not the BILLING PARTY proof of 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon m it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />--U til SeG��O t'1 �/l "-rte <br />X11 /� ra S . <br />ACCEPTED BY: Lot <br />VVV <br />EMPLOYEE #: D <br />DATE: / 21 <br />ASSIGNED TO: <br />, <br />EMPLOYEE#: g <br />DATE: <br />Date Service Completed (if alt <br />y completed): <br />SERVICE CODE: 2 <br />P t E: 1(/01 <br />Fee Amount: 4 wr VU <br />Amount PaidkpI <br />a �� <br />Payment Date <br />(PZ912- <br />Payment Type (le— <br />Invoice # <br />Check # 372– <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />