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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS E] <br />FACILITY ID # <br />COMMENTS: <br />ERVICE REQUEST # <br />2022 <br />PHONE # EXT. <br />( ) q �'C 6 <br />HOME or MAILINGADDRESS <br />SAN �pAQUIN <br />1Y <br />Cy 15711 <br />3'1122l-oa <br />HEALTH,D aRNT <br />(AX# ) <br />CITY <br />'41 cll�a_ <br />STATE ZIP /q <br />OWNER / OPERATOR <br />EMPLOYEE #: <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: <br />f I <br />Date Service Completed (if already completed): <br />�c^1'vl r <br />SITE ADDRESS 1 f <br />f D <br />Fee Amount:1yr 12(j �- <br />r`/ � P -V <br />ee <br />2G� 12 2 <br />Payment Type <br />�S 2f�e ri7 <br />Street <br />Nmnber <br />Direction <br />T Y Srr�ee\t <br />C <br />Name <br />Cit <br />Zi Code <br />ROME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />( ) <br />1 t(_.z70__ <br />PHONE #2 <br />( 1 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR_Q <br />( .a. 6 61 <br />0 LC I f ` �I <br />CHECK If BILLING ADDRESS E] <br />COMMENTS: <br />BUSINESS NAME �- <br />2022 <br />PHONE # EXT. <br />( ) q �'C 6 <br />HOME or MAILINGADDRESS <br />SAN �pAQUIN <br />1Y <br />3'1122l-oa <br />HEALTH,D aRNT <br />(AX# ) <br />CITY <br />'41 cll�a_ <br />STATE ZIP /q <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, Standard TA nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNER 11 PE O111 /MANAGER ❑ OTHER AUTHORIZEDAGEN'ffA <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule O <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, geoteclmical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at to it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: SS5 ,V `--'S <br />COMMENTS: <br />2022 <br />SAN �pAQUIN <br />1Y <br />HEALTH,D aRNT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: e'P2-� ZZ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1577-3 <br />P 1 E: -7&0 Z <br />Fee Amount:1yr 12(j �- <br />Amount Paid 2L <br />Payment Date <br />2G� 12 2 <br />Payment Type <br />Invoice # <br />Check # lo?) <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />