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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME I (� �C' �[} rr Fa 1, I 1 /��1 1�� Lf <br />I <br />0 Exr. <br />PHO r'(y . 2,5 <br />ail `1 1 <br />HOME Or MAILING ADDRESS W 51 Q Y r " I I' � Y I� I I (} ��� <br />v C G Y Cj <br />FACILITY ID # <br />0q� <br />CITY, l wviGn STATE G(� ZIP (� eLl "Z <br />SERVICE <br />�I�dbg��l+ <br />REQUEST # <br />OWNER / OPERATOR y <br />, i� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME 1A,G 1 <br />Y� <br />F <br />q ill i j , o rT� () c, <br />V1 C/ <br />L <br />ASSIGNED TO: <br />�i <br />SITE ADDRESS Gil C <br />Street Number <br />rU <br />Direction <br />EMPLOYEE #: ��)� <br />/� <br />tit <br />(��I�t <br />Street Name <br />U�tC�s],q <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />GC)q <br />Street Name <br />I�j <br />CITY <br />Amount Paidl <br />STATE ZIP <br />Z 23 <br />PHONE #1 <br />( ) <br />EXT° <br />APN # <br />Invoice # <br />LAND USE APPLICATION # <br />Check # is <br />PHONE#2 <br />( ) <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR 1 Iv V �Q ir CHECK if BILLING ADDRESS <br />BUSINESS NAME I (� �C' �[} rr Fa 1, I 1 /��1 1�� Lf <br />I <br />0 Exr. <br />PHO r'(y . 2,5 <br />ail `1 1 <br />HOME Or MAILING ADDRESS W 51 Q Y r " I I' � Y I� I I (} ��� <br />v C G Y Cj <br />FAX# <br />( ) <br />CITY, l wviGn STATE G(� ZIP (� eLl "Z <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 <br />COUNTY Ot dinattce to be performed will be done in accordance with all SAN JOAQUIN <br />Codes, Standar <br />APPLICANT'S SIGNATURE: ,v _ <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANA ER <br />If APPLICANT is trot the BILLING PARn proof <br />DATE' <br />OTHER AUTHORIZED AGENT ❑ <br />orization to sign is required <br />Title <br />en applicable, I, the owner or operator of the property located at the <br />above site addl•ess, hereby autholize the release of any and all results, geotechnical data Al <br />AUTHORIZATION TO RELEASE INFORMATION: Wh <br />environmental/site assesslnent <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. <br />TYPE OF SERVICE <br />REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />C , pV�s <br />EMPLOYEE #: I V�� <br />DATE: <br />04Z 3 <br />ASSIGNED TO: <br />�: `rS <br />rU <br />EMPLOYEE #: ��)� <br />DATE: L f 2 <br />(/73 <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( I <br />P / E: <br />GC)q <br />Fee Amount: <br />I�j <br />Amount Paidl <br />Payment Date <br />Z 23 <br />Payment Type <br />Invoice # <br />Check # is <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />