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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 v 6 ' 11FACILITY <br />ID # <br />SERVICE REQUEST # <br />BUSINESS NAME <br />h� <br />NO U4 <br />PH NE# Ezc <br />OWNER /OPERATOR <br />G r F <br />r <br />1 P0. J <br />Ci <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME <br />5u <br />FAX# <br />SITE ADDRESS 60q <br />>✓ slot - 1-`T -7 <br />I Por-r�2 S7L <br />CITY 16 --Teo L <br />C�To� <br />5, <br />Street Number <br />Direction <br />Street Name <br />- <br />EMPLOYEE#: �—y q/ <br />CO <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />SERVICE CODE:' S;2 % <br />-7055 � I L fT <br />(//� t / / i VI—Street Number <br />Street Name <br />CITYSTATE <br />OGALTOr� <br />ZIP <br />CA q s o -7 <br />PHONE#1 E". <br />P41 God— q57 �ilv <br />Payment Type <br />APN# <br />LAND USE APPLICATION# <br />PHONE#2 Ext• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR :.wWfir: EM e <br />REQUESTOR_ <br />JM C <br />CHECK If BILLING ADDRESS <br />r/�/t � <br />O <br />BUSINESS NAME <br />h� <br />NO U4 <br />PH NE# Ezc <br />en- <br />O —7 5 9v <br />HOME or MAILING ADDRESS <br />�OBPARTrAC <br />FAX# <br />a -7 <br />>✓ slot - 1-`T -7 <br />( ) <br />CITY 16 --Teo L <br />C STATE ZIP c75'do el <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, Standa=SaEDERAL aw <br />APPLICANT'S SIGNATURE: vim— DATE: -,1/o ZJ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT <br />IfAPPL/CANTis 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 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. w <br />TYPE OF SERVICE REQUESTED: 'SIC h <br />COMMENTS: <br />l�DJ m 3 @ aGeo. cvyYl <br />h� <br />NO U4 <br />dOAQUI ?O?l <br />�OBPARTrAC <br />ACCEPTED BY: LA (n <br />EMPLOYEE M <br />DATE: 2 <br />ASSIGNED TO: ( <br />- <br />EMPLOYEE#: �—y q/ <br />DATE: <br />Date Service Completed (if alrea y completed): <br />SERVICE CODE:' S;2 % <br />P I E: l &0it <br />Fee Amoun : S <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # A <br />4it l a I <br />Received By: <br />EHD 48-02-025 V SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />