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SAN JOAQUI.N . OUNTY ENVIRONMENTAL HEALTH L _?ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAMEa <br />SUJ �`�eu Ls <br />FACILITY ID # <br />SERVICE REQUEST # <br />�. DIS -7IPZQQP <br />OWNER/OPE <br />TOR <br />G' �Q� �j <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />EMPLOYEE #: <br />ADDRESS <br />stre.t�m Inaction <br />RroetName <br />EMPLOYEE #: <br />7 <br />4v� <br />IZi Code eSITE <br />HOME or MAILING ADDRESS (If 17rent from <br />Site Address) <br />Street Number <br />CODE: /`/I <br />street Name <br />CITY <br />Fee Amount: 1-4)-7 DO <br />STATE LP <br />PHONE#1xT <br />I 1 <br />1 <br />Payment Type V-� <br />AP14 <br />LAND USE APPLICATION # <br />PHONE #2 <br />En. <br />Received By: <br />BOS DISTRICT <br />LOCATION CODE <br />CON*ACTOR / SERVICE REQUESTOR <br />REQUESTOR �n CHECK if BILLING ADDRESS <br />v` <br />BUSINESS NAMEa <br />SUJ �`�eu Ls <br />PONE En' <br />�[3- �eo3 g <br />HOME or MAILING ADDRESS ` ,l b f A U �� <br />0 L �} <br />lA%# ) <br />CITY i p� STATE C A ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersignedoperty or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONME L HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed tome or my business as identified on this rm. <br />also certify that I have prepared this application and that the wo c to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. s! <br />APPLICANT'S SIGNATURE: v ' o t DATE: //U� Ola 00 ( � [� <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTH R AUTHORIZED AGENT ® LO t� o ( Q rl /-Q y'- ue <br />If APPLICANT is not the BILLING PARTY proof of alltllorizatlo to sign Is required Tire <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the ner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnica ata and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is vailable and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />Z) Vx 1 <br />�� p'4Y <br />COMMENTS: <br />/ <br />G' �Q� �j <br />� CFfj/ 'h <br />191 <br />oL� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE. <br />ASSIGNED TO:cm-An <br />f"LA <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already co pleted): <br />_lvSERVICE <br />CODE: /`/I <br />PlE:a30$ <br />I <br />Fee Amount: 1-4)-7 DO <br />I Amount Pa /7.06 <br />1 Payment Date <br />1 <br />Payment Type V-� <br />I <br />Invoice # <br />Check # 15299, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />