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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />` SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />e � CHECK if BILLING ADDRESS <br />SERVICE REQUEST ## <br />�K <br />OWNER/ PERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />(1 I <br />L I^� <br />C C) <br />SITE ADDRESS`UC <br />Street Number <br />Direction <br />C, <br />Street Name <br />�`c ` <br />Cit <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />ASSIGNED TO: Ff['tt1 k. 6 <br />Street Name <br />CITY <br />•S�ac���� <br />STATE Zip <br />C1SZlS <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( I <br />BOS DISTRICT <br />Amount Paid <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�� � <br />JI <br />�✓�OW\ `� <br />e � CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />C�o°J�g6- <br />PHONE# EXT. <br />HOME Or MAILING ADDRESS <br />(1 I <br />L I^� <br />C C) <br />(Ax # 1 <br />CITY S I O C� <br />STATE ZIP(' C• 7 C <br />O ✓� <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, ST a FEDE <br />APPLICANT'S SIGNATURE:Y=:ZDATE: t o - S 2 - <br />PROPERTY/ <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />if APPLICANT is not the BILLING PARTY• proof of authorization to sign is required Title /� <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property 0crI l� <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sib�%` <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the ame ti i D <br />provided to me or my representative. UCr 0 A; ,_ <br />TYPE OF SERVICE REQUESTED: Ve91 Cy setio ick.S f p ,0i- cover- 9, Lu,'1cJir4 PermtI � <br />COMMENTS: rjCifl'Q ewer IS e4nd be)1nj peyw,ffed. VC(I1!' <br />GTtp Jj►r,� <br />5etbe,(.4 fD SrP})L 5Y5h1V1- /4.0 Sept)r <br />Pe'M"-< 017 <br />C�o°J�g6- <br />►,� <br />CD ' msp-r� I�r• <br />aq `lour, hvitLe. <br />ACCEPTED BY: — � Z [, <br />EMPLOYEE #: <br />DATE: 'O S a Z <br />ASSIGNED TO: Ff['tt1 k. 6 <br />EMPLOYEE #: <br />DATE: 1045-A ? <br />Date Service Completed (if already completed): <br />SERVICE CODE: Ob / <br />P / E. ya as <br />Fee Amount: $ <br />Amount Paid <br />Payment Date <br />�2 Z <br />r <br />Payment TypeInvoice <br /># fl <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />ry <br />