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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTT-1 DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />C'�'1-A10Cao <br />7'�f91 <br />S2oa43Gq.2., <br />OWNER/ OPERATOR <br />(� <br />CHECK If BILLING ADDRESS <br />PHONE # <br />j) <br />EXT. <br />�j' i��- `/•�%� L <br />FACILITY NAME <br />f `D�'-1 C� <br />ASSIGNED TO: C47—A A.)4 A <br />SITE ADDRESS <br />DATE: <br />Fv ej Ile o <br />T�Z <br />5 Z c,Street <br />Number <br />Direction <br />Amount Paid <br />Street Name <br />Cit <br />i Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />! (e L <br />I' sit , k- )e <br />l <br />STATE C a <br />Street Number <br />Street Name <br />CITY S�aC C <br />STATE C i4 ZIP <br />EXT. <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />(2, -) 9Ys- -9YIZ <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />(2�3 S7ci3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />PAY <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />�Il <br />AUG 2 6 2005 <br />SAN JOAQUIN COUNTY <br />BUSINESS NAME <br />( <br />v o lCt,��Se-oma �. i <br />PHONE # <br />j) <br />EXT. <br />�j' i��- `/•�%� L <br />EMPLOYEE #: "y / <br />f `D�'-1 C� <br />ASSIGNED TO: C47—A A.)4 A <br />(Z�• <br />DATE: <br />HOME or MAILING ADDRESS <br />SERVICE CODE: <br />FAX # <br />Fee Amount: , �� c , 00 <br />Amount Paid <br />" <br />Payment Type <br />Invoice # <br />CITY S `CAlC-� t <br />Received y: <br />STATE C a <br />ZIP 9 S- ZO <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 or <br />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: �(Z /° <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPL/CANT is 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. <br />TYPE OF SERVICE REQUESTED: L(S %' „� T�-d I <br />PAY <br />COMMENTS: <br />AUG 2 6 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />DEPARTMENT <br />HEALTH <br />ACCEPTED BY: C) L C V�e ( a <br />EMPLOYEE #: "y / <br />DATE: v(0— <br />ASSIGNED TO: C47—A A.)4 A <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: , �� c , 00 <br />Amount Paid <br />" <br />Payment Date �s <br />Payment Type <br />Invoice # <br />Check # <br />Received y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />