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' SAN JOAQUIN %-OUNTY ENVIRONMENTAL HEALTH L—, ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cb o <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> INK Ix <br /> d <br /> SITE ADDRESS &t pp LkrOu <br /> Street Number I Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 CEH'CirRV o NtC pRl V <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> C'A 9 042.3-1 <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (714 ) 41t)-G1150 1027- o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR r�— <br /> REQUESTOR CHECK if BILLING ADDRESS r <br /> A <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> .L600 �, <br /> (sic) 1 �.r't - 839 L <br /> CITY SAIM STATE ZIP <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 /> c� % <br /> APPLICANT'S SIGNATURE: �� �;, ts-- DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHE AAUTIHORIZEDAGENT 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 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 /> TYPE OF SERVICE REQUESTED: T 44—`` M G, 4-L- RECEIVED <br /> COMMENTS: n LIS-eS I DEC 6 2005 <br /> 'l SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1, j _A EMPLOYEE#: ti - DATE: t (' C(r'" <br /> ASSIGNED TO: EMPLOYEE#: 5'� DATE: Z &,r S <br /> Date Service Completed (if already completed): SERVICE CODE: S PIE: A3 C <br /> Fee Amount: ? h� _ 3-7,cc Amount Paid bU Payment D to �2 1 (0 1 ()5 <br /> Payment Type ✓ Invoice# Check# S�s 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />