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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1W19'J'e 1!!�2 /Y? <br />,+n1 <br />FACILITY <br />�ID(�# <br />BOD J / S� <br />EEQUESS! T(# <br />SERVICE REQUEST <br />5 lz_)(- / 7t l <br />OWNER f OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />a�) — Q r <br />SITE A^nRFcc <br />AStreet Number <br />� <br />Ire tion <br />/� % � � <br />Street Name <br />✓ � <br />C'it <br />Zip Code <br />HOME or MAILING Annoree iu ^Ifferent from Site Address) <br />Street Number <br />d !� /�- "�✓ <br />Street Name <br />CITY _ ' / <br />[� <br />STATE,ZIP -7-5W <br />PHONE #1 <br />ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( I <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR t <br />/,e�i�'►� t�4 �/ .sr <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME � �6 <br />COMMENTS: <br />PH N� � � �EXT. <br />i <br />HOME or MALLiN2 ADDR�FAX <br />N� �r <br />,vTf�6e�,(' � <br />EMPLOYEE #: <br />a�) — Q r <br />CITY 1 / ^ _1 <br />STATE ZIP Js� t_ <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 jnd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE:NZICI <br />t' <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENTI <br />If APPLICANT is not the 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 />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. <br />TYPE OF SERVICE REQUESTED: S <br />AYNIENT <br />COMMENTS: <br />AUG 2000 <br />SAN JOAQUIN COUNTY <br />HEALTH )WENTAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #:Ah <br />DATE: <br />Date Service Completed (if already com ): <br />SERVICE CODE: <br />PIE: <br />Z <br />Fee Amount: 2 8 '^ <br />Amount Paid <br />s <br />Payment Date <br />6 <br />Payment Type 7 <br />Invoice # <br />Check # s 3 S <br />Received By: (r <br />EHD 48-02-0255 B►� SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />