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to 6 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />-]F,9 <br />FACILITY ID # <br />SERVICE REQUEST # <br />G c,s <br />PHONE# <br />Icp! <br />-00 I q 191 <br />N 7 <br />OWNER /OPERATOR <br />(909) <br />1-12— <br />1-4 6, ` -S 11-12— <br />S . <br />STATE Cc, <br />CHECK if BILLING ADDRESS <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ftPIE: <br />FACILITY NAME <br />Fee Amount: - <br />1 <br />SITE ADDRESS <br />— <br />Payment Date <br />Payment Type <br />S2 <br />Street Number Direction <br />Street Name <br />Received By: <br />Cit <br />Co) <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ` EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />` <br />ST <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />E\� �U -rc�ctc�t` <br />PHONE# <br />Icp! <br />EXT• <br />"A <br />HOME Or MAILING ADDRESS ` ` <br />EMPLOYEE #: 10k4 <br />(909) <br />1-12— <br />1-4 6, ` -S 11-12— <br />CITY <br />CITY <br />STATE Cc, <br />ZIP 7 <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, Stand rds, STATE and FEDERAL\ lawns. <br />APPLICANT'S SIGNATURE:C)the <br />�.(� _ �3 DATE: c)s <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IQ �y <br />If APPLICANT is 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 envi`i''o4mr'i�t?:a�_ i� h4 assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabi?fmafi6t/fujj� time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:' <br />ST <br />° 19H 2005 <br />COMMENTS: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />s <br />EMPLOYEE #: 10k4 <br />DATE: 313 bs <br />ASSIGNED TO: jo `h <br />EMPLOYEE #: S-373, <br />DATE: 3/314.c 31 D.c <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ftPIE: <br />z3o g <br />Fee Amount: - <br />1 <br />Amount Paid <br />— <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # ,�'� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />