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SAN JOAQUIN COUNTY ENVIRONA UNTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />tiECEIVEC <br />APR 3 0 2015 <br />Type of Buainess or Property <br />t:NECKifEtj�Iyl$Ij,ADORESa <br />FACILITY ID # <br />SERVICE R <br />P E �% EXT <br />J' <br />HOME or MAILING ADDRESS 2-535 <br />ACCEPTED BY: C� D d (T <br />`•+1 <br />OWNER I OPERATOR <br />STATE ZIP G <br />ASSIGNED TO: O <br />V <br />Vl <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SERVICE CODE: <br />SIfEADDRESS {1 <br />St <br />I <br />4CA f o <br />Amount P <br />3 O D <br />Payment Date <br />Number <br />Directl'n <br />invoice # <br />Na <br />C <br />Cotle <br />HOME of MAIUN ADDRESS (if Dlfferent-from Site Address.) <br />S". Number <br />Street Name <br />CITY J� <br />STATE ZIP <br />PHONE #1 <br />Exr• <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 <br />IFBOS <br />DISTRICT <br />(-OCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />` ' <br />l <br />t:NECKifEtj�Iyl$Ij,ADORESa <br />BUSINESS NAME <br />pp � i <br />LUI lJ <br />COMMEWS: <br />P E �% EXT <br />J' <br />HOME or MAILING ADDRESS 2-535 <br />ACCEPTED BY: C� D d (T <br />`•+1 <br />CITY5 <br />STATE ZIP G <br />MENTAL <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 DEPART,%fENr 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 />APPL,ICAWS SIGNATURE: ^ �,k%-) DATES c, <br />PROPERTY/ BUSINESS OWNERQ OPERATOR /:MANAGER O?HERAUTHORIZEAAGEIVT 'Ti <br />�f4Se111a ��� • . <br />Xf APPL1CAAT is not the BILUNCPAR proof of authorization to sign is required Title <br />AUTHORIZATION TO ULEA§E MgEMATIOD(: When applicable, I, the owner or operator of tie property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data artd/or- e#Yiroumental/site assessment <br />information to the SAN JOAQUIN COUNTY FNVIRQNMENTAL HEALTH DEPARTIViENP as soon as it is available and at the same time it Is <br />provided to me or toy representative. <br />TYPE OF SERVICE REQUESTED: <br />11 i <br />COMMEWS: <br />ACCEPTED BY: C� D d (T <br />`•+1 <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: O <br />V <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed `(if already completed); <br />SERVICE CODE: <br />P 1 Ec 2- --YJ b <br />Fee Amount: 'Jq V <br />Amount P <br />3 O D <br />Payment Date <br />— <br />15///b <br />Payment Type �� <br />invoice # <br />Ch # 36 <br />Received By: <br />EHO 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />