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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />D CHECK If BILLING ADDRESS <br />0 -Z— C- <br />FACILITY ID # <br />FL:, d <br />SERVICE REQUEST # <br />el L) <br />OYv�/�QL� <br />MAR 03 1011 <br />HOME or MAILING ADDRESS <br />OWNER /OPERATOR <br />1 f I^ <br />Or V <br />1. <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HFALTH DEEAMROPMENTAL TY <br />ARTMENT <br />t <br />SITE ADDRESS <br />L� r <br />ACCEPTED BY: t/1/1 <br />I w/ <br />Cft �� � <br />23 <br />1 Street Number <br />Direction <br />et Name <br />A Coda <br />HOME Or MAILING ADDRESS (If Different from Site Address)/� <br />SERVICE CODE: <br />C <br />Fee Amount: <br />152 - <br />Street Number <br />✓ t' <br />'� 1 J $treat NameJ� ' <br />CITY <br />Payment Date �Z <br />Payment Type <br />STATE ZIP <br />'5� Seo `t <br />PHONE#1 EXT• <br />Check # <br />APN# <br />LAND USE APPLICATION# <br />I20() C�36- �6C4v <br />PHONIER EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />(20 > , N - 8i_LCI <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR / <br />1 a ut v— <br />VVV V <br />D CHECK If BILLING ADDRESS <br />0 -Z— C- <br />BUSINESS NAME <br />A du <br />FL:, d <br />PHONE# ExT. <br />el L) <br />OYv�/�QL� <br />MAR 03 1011 <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY C L <br />1. <br />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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: / �- �DATE: 3 3120 2 -2— <br />PROPERTY/ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PARTY proof 0f authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at Ute <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 />w. <br />TYPE OF SERVICE REQUESTED: <br />C� <br />�/�.MM N 1 <br />Rae <br />COMMENTS: <br />uw <br />OYv�/�QL� <br />MAR 03 1011 <br />a"JOAQUIN COUN <br />HFALTH DEEAMROPMENTAL TY <br />ARTMENT <br />ACCEPTED BY: t/1/1 <br />EMPLOYEE#: <br />DATE: 3 <br />Z� <br />ASSIGNEDTO: ��S <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P /E: <br />Fee Amount: <br />152 - <br />Amount Paid <br />52 OD <br />Payment Date �Z <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD REVISED 10/217/2003 ? D 5�3 3 6 SR FORM (Golden Rod) <br />