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r. <br />SAN JOAQTTrNT COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />• SERVICE REQUEST <br />I of Business or Property <br />FACILITY.ID.#__ . <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />MAR 9 2009 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME C ` <br />VIRONMENTAL <br />NIT <br />SITE ADDRESS qW� <br />Street Number <br />I Direction <br />I Street Name <br />ASSIGNED TO: <br />Lod <br />City <br />52 <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) N/A <br />Street Number <br />Date Service Completed (if already completed): <br />�y /� <br />t �/ Street Name <br />CITY Al I[� <br />��1`(� <br />Fee Emoun:tA�JS " <br />STATE ZIP <br />Ex -r. <br />PHONE #1 <br />Payment Type <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT A <br />LOCATION ODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR '6111c) frciv CHECK If BILLING ADDRESS <br />BUSINESS NAME PHONE /I; _ s EXT' <br />IQ 51 <br />HOME or MAILING ADDRESS FAX # <br />CITY STATE ZIP <br />BILLING ACKNOVVLEDGENIENT: I, the undersigned property or business owner, operator or autnorizea 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: DATE: 2.L� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT a ? f :Iwi ,{ I � �L\ <br />If APPLICANT is not the BILLINGPARTY 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 />.,rnvirierl to me or my representative. <br />T YPE OF -SERVICE REQUESTED: S (f <br />COMMENTS: <br />pAyhAENT <br />RECEIVED <br />MAR 9 2009 <br />SANNOTM <br />VIRONMENTAL <br />NIT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />Y <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P / E: 23u <br />Fee Emoun:tA�JS " <br />Amount Paid <br />0 <br />Payment Date v g <br />Payment Type <br />Invoice # - <br />Check # — <br />Received By: <br />EHD 48-02-025 'SR fORM'(Golden Rod) <br />REVISED 11/17/2003 <br />