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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />f�� � /' f n ^ � <br />����j <br />Ptj�ONE <br />RAO 0 r o <br />HOME Or MAILING ADDRESSD'65v� 0i �� <br />E AQW <br />hFA[N �t NDN AC <br />OWNER/ OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ZIP C) - <br />DATE: YJ t <br />V (� l <br />ASSIGNED TO: w!' <br />EMPLOYEE #: 17 <br />DATE: <br />SITE ADDRES <br />J <br />_ Hard � {'1 �j V V a <br />1� I U a' � k'Y ! <br />Faila;o <br />Street Number <br />ctlon <br />3 <br />Str et Name <br />Invoice # <br />it <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #t EXT. <br />( I <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR . <br />/n r I F� r j' I I I -e 1Yfi <br />(� CJ I I I <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME i r In� n�a n��� ' <br />f�� � /' f n ^ � <br />����j <br />Ptj�ONE <br />, y y •2 �� EXT, <br />HOME Or MAILING ADDRESSD'65v� 0i �� <br />E AQW <br />hFA[N �t NDN AC <br />F(zC1 <br />CITY 3+6041)+W <br />STATE li l l <br />ZIP C) - <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TATE and FEDERAL laws. / <br />APPLICANT'S SIGNATURE: ° �1. DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ , ay•l <br />If APPLICANT 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 />%fid ems„ _ <br />TYPE OF SERVICE REQUESTED: ! <br />I �fi �>�' 06)%'#a <br />COMMENTS: <br />COMMENTS: <br />D <br />C Q <br />l�� ei D U�� <br />v V <br />f�� � /' f n ^ � <br />����j <br />20 <br />SAN jo <br />I <br />E AQW <br />hFA[N �t NDN AC <br />RT <br />MF <br />ACCEPTED BY: MIP'� <br />f r 1 <br />EMPLOYEE #: Z6 7 1) <br />DATE: YJ t <br />V (� l <br />ASSIGNED TO: w!' <br />EMPLOYEE #: 17 <br />DATE: <br />Date Service Compl ed (if airead ompieted): <br />SERVICE CODE: l ti( <br />PIE: 73 6V <br />Fee Amount: <br />Amount Pai 3 tSd2) <br />Payment Date <br />3 <br />Payment Type V1, <br />Invoice # <br />Check # 5 796 <br />Received By: <br />EHD'48=02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />