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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
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<br />FACILITY ID # SERVICE REQUEST #
<br />5 LYI TS
<br />OWNER! OPERATOR
<br />CHECK if
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<br /> BILLING ADDRESS
<br />NAME FACILITY NAME
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<br />SITE ADDRESS L 'I
<br />Street Number Number Direction
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<br />Street Name
<br />M At-J-7 E c A-
<br />City Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />P o ?),i4. 3 2.. Street Number Street Name
<br />Cm( STATE ZIP
<br />MPtf--17- CCA C tk °I c 3 3 co
<br />PHONE #1 Ex-r.
<br />(2-,Dct ) 73 Z_S— — 3,-,Q,:.
<br />I APN # LAND USE APPLICATION #
<br />PHONE #2 Err.
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<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR
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<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME
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<br />PHONE # EXT.
<br />HOME or MAILING ADDRESS
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<br />FAX #
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<br />CITY STATE
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<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 />APPLICANT'S SIGNATURE: ,AL-1/( c
<br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 12/ C isj I L., 61-N)(,—, E.E.,47.—
<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: .2/4..... 1 rtirifilf -g:-, g1-p 'le ' ' MkeY ........lealriC/77.7
<br />COMMENTS: -ECEiveo
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<br />ACCEPTED BY:
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<br />EMPLOYEE #: DATE: . '8 T ENT
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<br />ASSIGNED TO: Aiiir EMPLOYEE #: DAT .
<br />Date Service Completed (if already completed): SERVICE CODE: C P /
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<br />By:
<br />Fee Amount: k2
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<br />Amount Paid ---
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<br />Payment Date .,t
<br />Received Payment Type 01/11 cib Invoice # Check # (az/ 5cf
<br />DATE: 2.-/57L,D
<br />EHD 48-02-025
<br /> SR FORM (Golden Rod)
<br />REVISED 11/17/2003
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