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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# EXT. <br />( ) <br />FACILITY ID # <br />FAX# <br />) <br />SERVICE REQUEST # <br />I '�*C6 <br />( t�r1L <br />(� "S✓ J I <br />WN <br />121 <br />rc� <br />rQCCG <br />OWNER / OPERATOR_ <br />��� <br />CHECK if BILLING ADDRESS <br />V P/I Y <br />r 1 Vrn Fq rn ►w� <br />/I C - <br />FACILITY NAM <br />f <br />EMPLOYEE <br />#: <br />DATE: <br />ASSIGNED TO:�- c c d <br />EMPLOYEE <br />SITE ADDRESS <br />_ <br />�� I <br />Date Service Completed (if already completed): <br />S <br />SERVICE CODE: � <br />d <br />�Zi <br />O <br />Amount P <br />ls� U <br />r <br />Payment Date 3 �_ <br />Payment Type <br />Invoice # <br />Street Number <br />IQ rection <br />S�2t Name <br />cIt <br />Code <br />HOME or MAILING 14DD_RESS (If Different from Site Address)., <br />1T <br />�J <br />/Stteet <br />Q <br />1> <br />lV f 1 r Y✓� <br />S' 1 01 l� I <br />Number <br />osaeFNamp <br />CITY <br />1-�D JI . <br />STATESTATE ZIP <br />( q 5 o <br />PHONE #1 <br />Ex -r. <br />APN # <br />LAND USE APPLICATION # <br />�V <br />PHONE#2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />( ) <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 identified on this form. <br />I also cert <br />ify that I have prepared this application <br />COUNTY Ordinance Codes, Stan a/' TATE and <br />APPLICANT'S <br />PROPERTY /BUSINESS OWNER❑ <br />that the work to be performed will be done in accordance with all SAN JOAQUIN <br />IERAL laws. <br />r <br />/ MANAGER ❑ <br />DATE: <br />OTHER AUTHORIZED AGENT 11 <br />If APPLICANT is ►lot the BILLING PARTY, proof of autltariZation to sign is required <br />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. PA 4. ` <br />TYPE OF SERVICE REQUESTED: Ct,'(LS 5Q� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />\} <br />COMMENTS: <br />J <br />s� JaN 03 20 <br />Z <br />Fys/gQU1N <br />Hl�TH� 'V' co uN� <br />FNT <br />ACCEPTED BY: <br />EMPLOYEE <br />#: <br />DATE: <br />ASSIGNED TO:�- c c d <br />EMPLOYEE <br />M ��Cm <br />DATE: 6 / S/ Z2 <br />Date Service Completed (if already completed): <br />SERVICE CODE: � <br />, <br />P 1 E: <br />Fee Amount: Z� <br />Amount P <br />ls� U <br />r <br />Payment Date 3 �_ <br />Payment Type <br />Invoice # <br />Check # 1 <br />�� 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />