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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />OGl <br />`LII <br />- <br />FACILITY ID # <br />01 <br />BUSINESS NAME�� <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />1 I' <br />� <br />�J w <br />cj�mcka e <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: % y ZZ <br /># <br />Date Service Completed (if already completed): <br />SITE ADDRESS qW C <br />Street Number Direction , <br />(t xW Kf-r� � \� <br />v, \ Street Name <br />k. Loc7 � <br />CMCJ i54i iCSde <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />.1511- U <br />Fee Amount: 3 9 <br />Street Name <br />CITY^ <br />L`� <br />Payment Date <br />12-1,n <br />$TATE zipPHONE <br />#1 <br />( ) <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />PAYMENT <br />- <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME�� <br />ACCEPTED BY: <br />PHONE# ExT' <br />Ell R) EST <br />DATE:I <br />1, �_] <br />HOME Or MAILING ADDRESS,,FAX <br />EMPLOYEE #: % y ZZ <br /># <br />Date Service Completed (if already completed): <br />SERVICE CODE: y <br />CITY 2 c <br />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 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, Standards, STATE and FEDERAL laws. G <br />APPLICANT'S SIGNATURE: �r ln l �� DATE: iU ;I <br />PROPERTY I BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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: L��r �G) t <br />PAYMENT <br />- <br />COMMENTS: <br />- <br />RECEIVED <br />DEC 2 8 2011 <br />SAN 'MAOU N co.. <br />- HE_ - , :,c i'ARTkA <br />ACCEPTED BY: <br />EMPLOYEE#: q/�s <br />DATE:I <br />ASSIGNED TO: t T <br />EMPLOYEE #: % y ZZ <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: y <br />P f E: �, O <br />.1511- U <br />Fee Amount: 3 9 <br />Amount Paid <br />3� 5,— <br />Payment Date <br />12-1,n <br />Payment Type <br />Invoice # <br />Check # –711 p <br />Received By: (� <br />EHD 4&02-025 Std FCFR(VI (GoJdn Roel) s <br />REVISED 11/17/2003 <br />