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-)AINJVAl1UIIN I.VUINIY EINVll,(VINIVMEiNI'ALriLALlriDEFAKliV1EINI <br />• SERVICE REQUEST 6 <br />Tyy of Bu9:ness or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />5 <br />M 000 3-71 L <br />PHONE # <br />0� <br />Exr. <br />14 L I— 33 <br />OWNER /OPERATOR <br />PUBICES <br />EWIONLMENTM- HEALTH IC HEALTH VDIMSION <br />❑ <br />J J C'(O <br />APPROVED BY: JLA9 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />CITY O C ^ <br />STATE Q�c, <br />ZIP 9,,S-2 •— <br />10 <br />EMPLOYEE#: r <br />DATE: 3-5---3 <br />Date Service Completed (if already Completed): <br />SITE ADDRESS D <br />y <br />Y–\ c, <br />r e <br />Fee Amount: <br />Amount Paid <br />Street Number <br />Direction <br />Invoice # <br />Street Name <br />Check # D <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />109 -2 - <br />®mac.ZStreet <br />Street Number <br />Street Name <br />CITY �` �! <br />STATE C <br />ZIP <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />PHONE#Z Exi. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ENT <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />�c_�- c <br />PHONE # <br />0� <br />Exr. <br />14 L I— 33 <br />HOME Or MAILING ADDRESSAX <br />PUBICES <br />EWIONLMENTM- HEALTH IC HEALTH VDIMSION <br />_ <br />J J C'(O <br />APPROVED BY: JLA9 <br />) <br />�, 63 <br />CITY O C ^ <br />STATE Q�c, <br />ZIP 9,,S-2 •— <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: C>` DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT I, ��� <br />i <br />If APPLICANT is he 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 />infonnation 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. <br />TYPE OF SERVICE REQUESTED: <br />ENT <br />COMMENTS: <br />MAR 5 2003 <br />SAN JOAQUIN COUNTY <br />PUBICES <br />EWIONLMENTM- HEALTH IC HEALTH VDIMSION <br />P, <br />APPROVED BY: JLA9 <br />EMPLOYEE #: 2Z <br />DATE: — S a 3 <br />ASSIGNED TO: k-nW <br />EMPLOYEE#: r <br />DATE: 3-5---3 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />9 <br />PIE: 3 OF <br />Fee Amount: <br />Amount Paid <br />Payment Date ti / <br />Payment Type <br />Invoice # <br />Check # D <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />