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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />zoa�, <br />FACILITY 10 # <br />SERVICE RE UEST # <br />ORI OPERATOR <br />JIP <br />75 (UX` 5 S�j-� <br />CHECK if BILLING ADDRESS <br />FACa11Y NAME©" \� <br />ao W% <br />SITE ADDRESS <br />to Street Number <br />1�' <br />`� <br />Oil on <br />tName <br />cityZF <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SIMBItName <br />CITY <br />STATE ZIP <br />PH�nO/ANF.#1 EXT. <br />APN# <br />LAND USE APPLICATION# <br />PHONEN EXT, <br />808 DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTDR���jjj 1+ <br />e `Le11i <br />�5nLA-f <br />'1 <br />BILLING ACKNaWLEDGEMENT: ,I, the undersigned <br />CHECK if 61LLING ADDRESS <br />BUSINESS NAME 1 <br />PHONE# E�- <br />_t _ <br />Qn La, <br />tow <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br /> <br /> <br /> <br /> <br /> <br /> <br />property or business owner, operator or authorized agent of same, <br />acknowledge that all Site and/or project specif a 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 />L also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQum <br />CouNTY Ordinance Codes, Standards STATE and FEDERAL In <br />APPLICANT'S SIGNATURE: � (j _ _If0/I, DATE: r,aof*aa';l <br />PROPERTY i BUSINESS OWNERD OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />JfAPPLICANT is not the B/LL(NG 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 ato" t, f e it is <br />provided to me or my representative. RECEIVEn <br />TYPE OF SERVICE <br />31� ' <br />EHD b&02-025 <br />REQUESTED: C <br />COMNENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:EMPLOYEE#: <br />OggDATE: <br />ASSIGNED 70: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: K <br />Fee Amount:LY <br />/ Amount Paid <br />I <br />' 5 a r <br />Payment Datetri <br />Z <br />Payment Type <br />J p A` <br />Invoice # <br />5tee cr# f 4' b D (3 <br />Received El <br />a3lSR FORM (Golden Rod) <br />REVISED 7 111 7 /20 03 <br />