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SAN JOAQUI00UNTY ENVIRONMENTAL HEALTI0PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />MMFNT <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME- / <br />/�J <br />P,�� <br />EXT. <br />L <br />0 7 <br />r, <br />EMPLOYEE M <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX# <br />OWNER 1 OPERATOR <br />PIE: <br />Fee Amount: <br />CITY 6,�� J <br />STATE <br />ZIP -50"?2 <br />CHECK 1f BILLING ADDRESS <br />FACILITY NAME <br />Invoice # <br />Check # �qq �l3 �( <br />Received By: <br />SITE ADDRESS/ <br />r <br />Street Number Direction <br />t Name <br />( zi ode <br />HOME or MAILING ADDRESS (If Different from <br />Site Address)I' <br />6inc�' Liz <br />Street Number <br />2/ / <br />r t <br />CITY 7 <br />STATE <br />ZIPS'] <br />PHONE #t EXT.APN <br /># <br />LAND USE APPLICATION # <br />(Z 3 <br />z-gl 1 '3/- �rsV <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />MMFNT <br />COMMENTS: <br />CHECK If BILLINGS ADDRESS <br />BUSINESS NAME- / <br />/�J <br />P,�� <br />EXT. <br />L <br />ASSIGNED TO: <br />EMPLOYEE M <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX# <br />G r.,e <br />PIE: <br />Fee Amount: <br />CITY 6,�� J <br />STATE <br />ZIP -50"?2 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY /BLsiNFssOWNER❑ OPERATOR/MANAGFR © OTHER AUTHORIZED AGENTI� <br />IfApive.4,w, is not theBILLIA�G P,9RTY. 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 JOAQUrN COUNTY ENVIRONNmI NTAL 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: LAJ' " <br />MMFNT <br />COMMENTS: <br />RECEIVED <br />AUG 2 9 2012 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECool7; <br />PIE: <br />Fee Amount: <br />Amount Paid <br />C7 0 <br />PaymeA <br />Date <br />Payment TypePv <br />Invoice # <br />Check # �qq �l3 �( <br />Received By: <br />EHD 46-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />