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• • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAMEPHONE# <br />Y,r <br />�� ., <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />C a <br />RECEIVED <br />AUG 2 2 1011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />10-7-7 <br />�iZ®��33a0 <br />�, <br />0)? ` -1 <br />DATE: - Z�t% <br />ASSIGNED TO: <br />g y C-'_I,tS <br />OWNER/ OPERATOR <br />3 j <br />Date Service Completed (if already Completed): <br />SERVICE CODE:/ 9 e <br />CHECK If BILLING ADDRESS IC! <br />le <br />Fee Amount: <br />3-7� 07) <br />FACILITY NAME <br />Payment Date <br />152-9 <br />Payment Type <br />I/Invoice # <br />SITE ADDRESS <br />R ceived y: <br />2- S er D Street Numb <br />Direction <br />Street <br />Name n <br />Ci <br />e <br />Zi Code <br />HOME 0 MAILING ADDRESS (If Different from Site Addr2��teet <br />Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(�;f L4— <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS El <br />BUSINESS NAMEPHONE# <br />Y,r <br />�� ., <br />EXT. <br />5 _- 1 <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />CITY STATE ZIP <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 th work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT F�and FEDERA aws. <br />APPLICANT'S SIGNATURE: _ DATE: W.2 -y ( k <br />PROPERTY/ BUSINESS OWNER OPE TOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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"% r✓%�—og-,C) F t 'T <br />COMMENTS: <br />RECEIVED <br />AUG 2 2 1011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />UE ---t <br />EMPLOYEE #: <br />0)? ` -1 <br />DATE: - Z�t% <br />ASSIGNED TO: <br />g y C-'_I,tS <br />EMPLOYEE #: <br />3 j <br />DATE: �>Izzfil <br />Date Service Completed (if already Completed): <br />SERVICE CODE:/ 9 e <br />I <br />P / E: �3 eiP <br />I <br />Fee Amount: <br />3-7� 07) <br />Amount Paid <br />Payment Date <br />152-9 <br />Payment Type <br />I/Invoice # <br />Check <br />R ceived y: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />