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SAN JOAQUI16OUNTY ENVIRONMENTAL HEALTHiPARTMENT <br />SERVICE REOUEST <br />,Type of Business or Property <br />CHECK if BILLING ADDRESS 14 <br />FACILITY ID # <br />� <br />VLA--� -.cu• <br />SERVICE REQUEST # <br />LIPS <br />� <br />Y <br />.2-6- t <br />CITY <br />� <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS E] <br />SERVICE CODE: i Cf (> <br />P i E: 1 3 Lk <br />FACILITY NAME <br />Amount Paid <br />V.E ADDRESS <br />�v�ret <br />cq <br />Code <br />L` Street Number <br />Name <br />t <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />D 01 8� <br />SR FORM (Golden Rod) <br />Street Number <br />3k S� <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATIT CODE <br />f-"1VTRAd-T(lR / 4ERVICF RFA) UFS'1'UK <br />REQUESTOR k ` _ p <br />CHECK if BILLING ADDRESS 14 <br />BUSINESS NAMEna (� t <br />�LYP6 <br />� <br />VLA--� -.cu• <br />PHONE # EXT. <br />ton <br />HOME Or MAILING ADDRESSP <br />� <br />Y <br />F # ) ,ICL 1 11 <br />IQ/ <br />CITY <br />� <br />STATE CAZIP ( 02 O <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnorizeu 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, STAT d FE L laws. <br />APPLICANT'S SIGNATURE:11 r DATE: Ic t Z3 <br />PROPERTY/ BUSINESS OWNER❑ PERATOR / M NAGER ❑ OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is no the BILGING 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/sitt, assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and. at kt�} A e time it is <br />provided to me or my representative. fix"., -i1 <br />TYPE OF SERVICE REQUESTED <br />COMMENTS: <br />00\3 0 <br />GO p,L <br />SP �Nv\P p PPR�M�N� <br />ACCEPTED BY: <br />l 0-4 <br />EMPLOYEE M 0 ?� 'Z'' <br />DATE: <br />icy <br />ASSIGNED TO: <br />'i G��S <br />EMPLOYEE #: Fi <br />DATE: <br />(� Z Z l 0 <br />Date Service Completed (if already completed): <br />SERVICE CODE: i Cf (> <br />P i E: 1 3 Lk <br />Fee Amount: <br />-� : , � , <br />Amount Paid <br />`S (� <br />Payment Date \b 2 S <br />Payment Type <br />✓ 5 <br />Invoice # <br />Check # '010 C� 115 A �qQ <br />Receiv d By: td'�S— <br />D 01 8� <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />3k S� <br />