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• 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Properly <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />PHE# <br />SERVICE REQU T # <br />7 1;/ <br />L1(OD an <br />FAX# <br />( I ) <br />�o h�3 <br />CITY }� STATE <br />S C 005 <br />OW ER / OPERATOR <br />J I <br />I � <br />DATE: <br />CHECK If BILLING ADDRESS <br />FACILITY NAMIU <br />p <br />SERVICE CODE: <br />P 1 E: <br />SITE ADDRESS <br />Amount Paid�Xff-¢ <br />l <br />Payment Date L p7 <br />Payment Type <br />Invoice # <br />Street Number <br />Direction <br />Street Name <br />city <br />ZID Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 51L (wCY1��%tl] <br />V(k'1V ) OC <br />Street Number <br />Street Name <br />CITY ` <br />` <br />STA Trj� p ZIP 5(; 1 <br />�1(� <br />`USE ,(APPLICATION <br />PHONE#1 ExT. <br />1 ) ��- o5rpb <br />APN# <br />-ola -1y <br />LAND # <br />PHONE#2 EXT. <br />I 1 <br />BOS DISTRICT <br />1 11/ <br />LOCATIOyCODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />1 Z �t en C�h�. <br />PHE# <br />EXT. <br />1- 3 D <br />HOME or MAILING ADDRES n <br />,u• a3� <br />FAX# <br />( I ) <br />II <br />,71-o <br />� 4 <br />CITY }� 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 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 JOAQu N <br />CouNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: KO l �Ak0�?, DATE: '4D-011 <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENTC`Y �lLC.1LZ�C�C <br />IfAPPLiCANT 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 avpilomltr and at the sante time it is <br />provided to me or my representative. ��'(i'►a n <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />� N <br />�N,OPQ NM�NS N <br />DE\'0j <br />SH���N\'j,0140 <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: 42 <br />ASSIGNED TOEMPLOYEE <br />#: D DO / <br />DATE: <br />Date Service Completed (if already complete(d): <br />p <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid�Xff-¢ <br />a4?tf, ov <br />Payment Date L p7 <br />Payment Type <br />Invoice # <br />Check # 3 <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />