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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Gcc� �c.�� v <br />lA 000 <br />�✓' GC% 17 �� <br />OWNER/ OPERATOR <br />❑ <br />CITY �Toc( Q STATE ZIP G� <br />9152 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />DATE: <br />3 1-3 � f U� <br />`7PIE: <br />Date Service Complet d (if already completed): <br />SERVICE COD�EE: �Ct <br />SITE ADDRESS C1 /lam <br />VIYy <br />2 � <br />\ <br />�7 <br />eC'Cl <br />_I <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />C' <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY `^ ^ �e C <br />�( \ <br />STATEZIP �'-- <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />' 013 -y <br />PHONE #2 EXT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR-r-le <br />CHECK If BILLING ADDRESS �OrI <br />BILLING <br />C <br />BUSINESS NAME\ i (`�` :_ <br />�A� c _, <br />PHONE# ExT., <br />G - <br />HOME or MAILING ADDRESS <br />FAX# <br />c' <br />c)9) - y� <br />CITY �Toc( Q STATE ZIP G� <br />9152 <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. 3 <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, Standds, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: C ADATE: <br />PROPERTY/ BUSINESSOWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTA777a" , <br />If APPLI5�CANT n the BILLRVG PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION' 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 Sam time it is <br />provided to me or my representative. `JM MEN� <br />•r f'l <br />TYPE OF SERVICE REQUESTED: R -C4; Drl <br />T <br />R - <br />COMMENTS: <br />MAR 3 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ViEALTH DEPARTMENT <br />ACCEPTED BY: r t244,tn <br />EMPLOYEE #: t v g <br />DATE: l/ M; <br />ASSIGNED TO: <br />G p <br />EMPLOYEE#: g%' <br />DATE: <br />3 1-3 � f U� <br />`7PIE: <br />Date Service Complet d (if already completed): <br />SERVICE COD�EE: �Ct <br />2 � <br />Fee Amount: p <br />�7 <br />Amount Paid ?t::? — <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 />