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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTI`EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />vA..) <br />BUSINESS NAM E, <br />C� <br />WNER/OPERATOR <br />;' <br />CHECK if BIWNG ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: <br />SITE ADDRESS <br />EMPLOYEE #: <br />'G <br />CITY1 Z <br />STATE ti zip 1 <br />Street Number <br />L)JMWM b C <br />P E: _ <br />Fee Amount: !S G� <br />Amount Paid <br />3 S, (� <br />HOME Or MAILING = (If Different from Site Address) <br />Date l ' <br />Payment Type <br />Invoice # <br />Street Number <br />Shyet Name <br />CITY <br />STATE zip <br />NONE #11 ExT• <br />APN # <br />LAND USE APrUCATION # <br />( L)j —1(,) -?1 <br />PHONE R ExT• <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / NER34CX41EAQJJfATM <br />REQUESTO <br />; <br />l � ' CHECK if BIWNG ADDRESS <br />0(—d12:29 <br />G` ( `<— <br />�V <br />BUSINESS NAM E, <br />DEC 1 6 zoo <br />SAN JOAQUIN COUNTY <br />NVIRONMENTAL <br />HEALTH DEPARTMENT <br /># EST. <br />EMPLOYEE # <br />_ <br />HOME or a LING A DRESS <br />ASSIGNED TO: <br />FAx # <br />EMPLOYEE #: <br />'G <br />CITY1 Z <br />STATE ti zip 1 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: 441— ,,,✓✓ DATE: <br />PROPERTY / BUSINESS OWNER ❑ O TOR / NAGER OTHER AUTHORIZED AGENT CI <br />IfAPPLICANT is not the BILLING PARTY, proof o 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. ooYMEN <br />TYPE OF SERVICE REQUESTED: GJ <br />4ECEIV <br />COMMENTS: <br />DEC 1 6 zoo <br />SAN JOAQUIN COUNTY <br />NVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE # <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P E: _ <br />Fee Amount: !S G� <br />Amount Paid <br />3 S, (� <br />Paymen <br />Date l ' <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 />