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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />S , VICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />�c,--'fit,© <br />ACCEPTED BY: O I lJ I ��� <br />EMPLOYEE M Q 3 Z <br />DATE: J <br />ASSIGNED TO: <br />OWNER/ OPERATOR <br />r <br />DATE: r l �/ 7 <br />CHECK if BILLING ADDRESS El <br />SERVICE CODE: / <br />FACILITY NAME Ll�cl 1,, IV 772 CII D L3, <br />D 7 <br />Amount Paid <br />SITE ADDRESS`-dC <br />J� <br />Street Number Direction <br />Street Name <br />City Zip Cod <br />HOME or MAILING %ADDRESS (If Different from Site Address) <br />r',C, / d j f� <br />Q]' 7tcJ <br />5 2,/ ti'L � <br />Street Number <br />Street Name <br />CITY <br />—� 7C_/ <br />STATE <br />ZI <br />V CI <br />PHONE #1 ExT• <br />(:-0)— yGz_ 095.2 <br />APN # <br />1 tZ3-/ei,-01 <br />LAND USE APPLICATION # <br />PHONE#2 ExT• <br />BOS DISTRICT <br />/ <br />LOCA'I'llCODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # ExT' <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />CITY STATE 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 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. <br />APPLICANT'S SIGNATURE: &/ � ���hE ec /\ DATE: <br />PROPERTY / BUSINESS OWNt O"' OPERATOR / MANAGER ❑ HER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 earid,0t tie time it is <br />provided to me or my representative. �..�Ar-(,ENEQ' <br />TYPE OF SERVICE REQUESTED: �C-�� O <br />SVO <br />COMMENTS: <br />SAN 3� cou NN <br />R NMN Et`R <br />HTt { DEPARTM <br />ACCEPTED BY: O I lJ I ��� <br />EMPLOYEE M Q 3 Z <br />DATE: J <br />ASSIGNED TO: <br />EMPLOYEE M / S S <br />r <br />DATE: r l �/ 7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P ! E: 2 3 <br />Fee Amount: �_ <br />Amount Paid <br />0 -,� <br />Payment Date <br />C (YJ 0 -7 <br />Payment TypeC•�� <br />Invoice # <br />Check # <br />Received By: -2�,L <br />EHD 48-02-025 ins--� b D �' 7 SR FQIvT (Golden F2od) <br />REVISED 11/17/2003 <br />