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1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE # Em <br />SERVICE REQUEST # <br />FAX # <br />CITY STATE ZIP <br />S <br />f'oci m �er <br />ry <br />OWNER/ OPERATOR <br />301- Cuadra <br />TI i� <br />CHECK If BILLING ADDRESS <br />e <br />h$ <br />MeAfT <br />FACILITY NAMEn � <br />Fln4p r+ -os I v l CA <br />Mas <br />SITE ADDRESS <br />.S <br />_ <br />/� <br />7f//�(CIIT V <br />'7ZI <br />13C) Street Number <br />Direction <br />if already completed): <br />,r�, <br />6t2MIYama <br />SERVICECODE: 5'2--3 <br />PI : V <br />Code <br />HOME or (NAILING ADDRESS (If Different from Site Address) <br />Amount Pai <br />_ % c"t 0 j) <br />Payment Date <br />1 U t b R n n hors Wa <br />Street Number <br />Street Name <br />CmSRC <br />Payment Type 64zer <br />CPrE ZIP 58Z6 <br />PHONE #1 Ex . <br />APN # <br />LAND USE APPLICATION # <br />(&n )14gl-,q(9Al2, <br />PHONE #2 Exr. <br />I ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK If BILLING ADDRESS <br />REQUESTOR nuar <br />BUSINESS NAME <br />PHONE # Em <br />HOME or MAILING ADDRESS <br />FAX # <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 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, f� / <br />APPLICANT'S SIGNATURE:. ,� DATE: V - (�-� zZ- <br />l�L� <br />PROPERTY / BUSINESS OWNSR,A//PERATOR /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 located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data .and/or envirorimentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as. Soon as It is available andaPf{i1e time it is <br />provided to me or my representative. 09 _ eN7- <br />TYPE OF SERVICE REQUESTED: <br />�VC�VED <br />COMMENTS: <br />u1i6 202,7 <br />feRON <br />COUN <br />H�TNOFpARTy <br />MeAfT <br />ACCEPTED BY: <br />EMPLOYEE #: 21 3 <br />DATE' g i b 7 Z <br />ASSIGNEDTO: <br />EMPLOYEE If: <br />DATE: ' <br />Date Service COmpl ed <br />if already completed): <br />SERVICECODE: 5'2--3 <br />PI : V <br />Fee Amount:6 <br />Amount Pai <br />_ % c"t 0 j) <br />Payment Date <br />Payment Type 64zer <br />Invoice # <br />Check # `+V S <br />Rec ived By: <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />�� �7� — 3 Ca -n <br />SR FORM (Golden Rod) <br />