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SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTH DLVARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILIT # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />C iO-S 516t-(WA <br />PHONE # <br />/ / 77 <br />'E�40WQ'340 <br />OWNER / OPERATOR <br />FAX # <br />//0 w R, SAe- ,J7-3 0 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />CHECK If BILLING ADDRESS <br />FACILITY NAME, �, ✓ �l O-7-7 O <br />�A !� j <br />� C <br />� /�� <br />SITE ADDRESS <br />l0 <br />ASSIGNED TO: <br />` <br />N <br />EMPLOYEE #: t _ 2 J _ <br />J C%JG)� <br />� � <br />O <br />Street Number <br />Direction <br />n <br />6 m <br />tore� <br />3q-5,00 <br />Cit <br />I Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />Street Number <br />Received By: <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />0 & � - 0 2.0 ---lS <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />11 <br />BOS DISTRICTLOCATION <br />Ll <br />ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR C / / - <br />L if�LL <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME�" <br />Q"L1vit of v v(Zoll <br />PHONE # <br />EXT. <br />3 ('3 — 1 b <br />HOME or MAILING ADDRESS <br />FAX # <br />//0 w R, SAe- ,J7-3 0 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />(a,h) <br />3 (o 6-- - l S `ti 3 <br />CITY LU _I z <br />STATE 04 - <br />ZIP C S 2. Lt Z) <br />BILLING ACKNOWLEDGEMENT: 1, 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. <br />APPLICANT'S SIGNATURE: DATE: (1 // �/r1� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 4,2 Q' -m'4— �--SSLf • `^'�" <br />If APPLICANT 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. <br />TYPE OF SERVICE REQUESTED: LSCS PAYMENT <br />COMMENTS: <br />RECEI <br />SEP 15 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />U C' <br />EMPLOYEE #://7 <br />DATE: r % <br />ol <br />ASSIGNED TO: <br />6 I t �iG� �.S <br />EMPLOYEE #: t _ 2 J _ <br />J C%JG)� <br />DATE: !�l <br />lZ <br />Date Service Completed (If already completed): <br />SERVICE CODE: <br />P 1 E: <br />nc� <br />Fee Amount. <br />3q-5,00 <br />Amount Paid <br />3L f � O -D <br />Payment Date q <br />Payment Type <br />Invoice # <br />Check # 14 L <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />