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SAN JOAQUIN ` ()UNTY ENVIRONMENTAL HEALTH"UPARTMENT <br />SERVICE ,REQUEST <br />Type of Business or Property <br />CHECK If BILLIN -, ADDRESS <br />i�FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESSFAX# <br />, <br />4a�DD03; 3 <br />60,4 2 <br />OWNER/ OPERATOR / y <br />, <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME 5h], J <br />i <br />EMPLOYEE #: 8373 <br />DATE: g/, i /0T <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />9S <br />SITE ADDRESS/ <br />� <br />�� <br />1� � ` <br />Payment Type ✓ <br />I <br />�b�y \ <br />Street Number <br />Direction <br />Received By: <br />61 Stre e <br />i <br />`ii`Co`de' <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY, n �I/� 1 <br />III( <br />TATE <br />ZIP <br />PHONE #1 ExT' <br />( ) <br />APN # <br />— <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLIN -, ADDRESS <br />BUSINESS NAME+ <br />E,h'i % �, <br />PHONE^ EXT. <br />HOME or MAILING ADDRESSFAX# <br />, <br />CITY (\ / Qr� zip <br />BILLING ACKNOWLED41ENI: 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 appl'eation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S AT and:J�EDERA a s. % <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Q -S <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. 2&MFN - <br />TYPE OF SERVICE REQUESTED: u� 1 <br />REC�Iv �v <br />COMMENTS: <br />NUI UIN COoN", <br />SAENNJ R NM R�IAENT <br />HEALTH pEPA <br />ACCEPTED BY: �L l2'`i� <br />EMPLOYEE #: 0 <br />DATE: W1 2 D4i <br />ASSIGNED TO: �� ��S . , <br />EMPLOYEE #: 8373 <br />DATE: g/, i /0T <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />9S <br />P / E: <br />Fee Amount:7Gj fi70 <br />Amount Paid � 1�� p iD <br />Payment Date �j �� [) <br />Payment Type ✓ <br />Invoice # <br />I <br />Check # q9 I-, <br />Received By: <br />EHD 48-02-025 'SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />