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SAN JOAQUIN r`1UN'I'Y ENVIRONMENI'AL HEAL'T'H "'VPARTMEN'I' <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />` j to <br />, <br />FACILITY ID # <br />FA 00 3 <br />SERVICE REQUEST # <br />c' 0 - e7 -'v <br />OWNER / OPERATOR <br />EXT. <br />CHECK if BILLING ADDRESS ❑ <br />///��� <br />FACILITY NAME �j , n <br />4540 („ <br />v; <br />FAX # <br />I& <br />)I's 3 <br />SITE ADDRESS ?c <br />Street Number <br />Direction <br />Street Name <br />S c <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />!MTAt HEALTH DIVISION <br />APPROVED BY: 1 /1 r <br />STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />ASSIGNED TO: 1 tT <br />h� <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Exr. <br />Date Service Completed (if already completed): <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR <br />^. �C CS <br />CHECK if BILLING ADDRESS <br />` j to <br />, <br />BUSINESS NAME <br />PHONE## <br />EXT. <br />RECEIVED <br />HOME or MAILING ADDRESS <br />L.)\ <br />FAX # <br />I& <br />)I's 3 <br />CITY S <br />A� 1 L� Q-A `(-,g <br />ZIP U^ <br />1 <br />J <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, Standen ds, STATE FEDERAL laws. q ( <br />APPLICANT'S SIGNATURE: /-� DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT IR AL) Q 1 - <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 COUN'T'Y 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: <br />J <br />V I <br />COMMENTS: <br />RECEIVED <br />SEP 410Qv <br />SAN JOAQUIN COUNTY <br />pup,l IC HEALTH SERVICES <br />!MTAt HEALTH DIVISION <br />APPROVED BY: 1 /1 r <br />EMPLOYEE #: Z L <br />DATE: <br />ASSIGNED TO: 1 tT <br />h� <br />EMPLOYEE #: S(x 4 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:rl <br />P I E: <br />Fee Amount: Z <br />Amount Paid 0?7— <br />-7 <br />Payment <br />Date <br />Payment Type �. <br />Invoice # <br />Check # ! _ 3 <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FOR <br />REVISED 6-5-02 <br />