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SAN JOAQACOUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUST ESS N E 7 <br />P►� "Pa� i L'- s�o I���w) <br />SERVICE REQUEST # <br />se'(�/ tC(1, S -46 1C" 1') <br />EXT. <br />46J-q�(� o <br />ccc (e �-3 <br />SEp _ 1 2409 <br />�'C M5Q2 VO— <br />OWNER/ OPERATOR <br />CITY <br />STATE <br />ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME S _E- <br />SITE ADDRESS ZC��% V <br />ACCEPTED BY: <br />CfiC.1F) + C- �� C � (.A b 2 <br />J 1 UG L7 r'� <br />�i�J�� t0 <br />Street Number <br />Direction <br />Street Name <br />City <br />i Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />P I E: ;23 o g <br />Fee Amount: <br />Street Number <br />Amount Paid <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT.APN <br />(Zoc1) q3 ` 13"� <br />✓ <br /># LAND USE APPLICATION # <br />C2-3 - oma --(v <br />PHONE #2 EXT. <br />( ) <br />Received By: Wr.— <br />BOS DISTRICT/ <br />I <br />LOCATIpN CODE <br />1/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUFSTQ <br />t{/& I Rhto e n O e n s k a <br />CHECK If BILLING ADDRESS IT <br />BUST ESS N E 7 <br />P►� "Pa� i L'- s�o I���w) <br />NONE # <br />1�� <br />EXT. <br />46J-q�(� o <br />HOME or MAILI�G ADDRESS <br />SEp _ 1 2409 <br />F? ## `, <br />CITY <br />STATE <br />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 HEAL -11-I 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 JOAQ1JIN <br />COUNTY Ordinance Codes, Standards STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �� C�� �� =t DATE: CD <br />PROPERTY / 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, 1, 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: <br />COMMENTS: <br />SEp _ 1 2409 <br />JOAOVtMgt�A (`( <br />SPN <br />�TM DEFA�-SEN <br />ACCEPTED BY: <br />QLt VE ( "A <br />` <br />EMPLOYEE #: O 3 2_` <br />DATE: 4/I fog <br />ASSIGNED TO: <br />r r C— <br />EMPLOYEE #: <br />DATE: f Q <br />Date Service Completed (if already completed): <br />SERVICE CODE: I C� r <br />P I E: ;23 o g <br />Fee Amount: <br />3 <br />Amount Paid <br />3 5 <br />Payment Date <br />Payment Type <br />✓ <br />Invoice # <br />Check # Z ` <br />Received By: Wr.— <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />