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SAN JOAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />too 2(4 Nq_7R <br />SERVICE REQUEST # <br />S�2 00 g 2(o Z <br />OWNER / OPERATOR <br />' V I <br />V <br />CHECK If BILLING ADDRES <br />V Ll/ ✓ t.r/ P " `-' <br />FACILITY NAME W 1 <br />N � <br />SITE ADDRESS 102 <br />Street Numb <br />Direction <br />` ( Street Name �� <br />Citl <br />^, <br />V <br />GS3SI <br />2i Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) I ,\ <br />Street Number <br />In ^ �i^ - <br />Y ✓, <br />Street Name r <br />CITY A ` <br />71 <br />i V t <br />M o <br />I'' <br />n <br />STATE '`,�- ZIP S2S <br />J <br />(itQNE J1 2 EST <br />S 5 ^ <br />NI (!fEM <br />APN # <br />LAND USE APvPLIC\ATION # <br />PHONE#2 <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE zip <br />BILLING ACKNOWLEDGE iNT: 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 forth. <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. <br />APPLICANT'S SIGNATURE: <br />DATE: )—I 'V J <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />ffAPPL]CANT is not the BILLING PARTY proof of authorization to sign is required Title <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, 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. , ro <br />TYPE OF SERVICE REQUESTED: <br />( <br />k—Anr <br />COMMENTS: <br />Viet) <br />MAI r 2.19 <br />SAN <br />�OAviliQIJ <br />HFq <br />T k OD �T l' <br />PARTTq <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />[PIE: <br />Fee Amount: <br />Amount P <br />/ ��D <br />Payment Date <br />l g <br />Payment Type <br />Invoice # <br />Check # <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />