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SAN JOAQUIN6UNTY ENVIRONMENTAL HEALTHJPPARTMENT <br />SERVICE REQUEST <br />Type of Business <br />or Property <br />fW IV rC� <br />(, FACILITY ID# <br />T -369V <br />SERVICE REQUEST # <br />Ow ER / OPERATOR <br />/I J <br />A 11 <br />HOME Or MAILING ADDRESS5' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />#`n) <br />Lm ,,, l� <br />(�A <br />/ m t <br />STATE ZIP <br />SITE_�DRESS` <br />Street N er <br />Directionmmrw <br />SERVICE CODE: <br />g <br />Stre ame <br />Fee Amount:z a <br />�Ci *�U- <br />I, <br />Zi Code <br />HOME or MAILING ADDRESS f Different from Site Address) <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE1 <br />i!1) q <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR^ �/ n <br />C� c-C� <br />• /�� <br />l <br />CHECK if BILLING ADDRESS <br />BUSINESS %TAMEExT. <br />kk <br />� 'r - <br />J UN <br />SAN", COUNTY <br />ENVIFIONMENTAL <br />HEALTH DEPARTMENT <br />PH5 <br />HOME Or MAILING ADDRESS5' <br />�� rFAx <br />uC C <br />qC1 <br />#`n) <br />CITY <br />/ m t <br />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 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 app •cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FEDERALw .. <br />APPLICANT'S SIGNATURE:( �a� , X <br />�C DATE: <br />ff <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTt:"/ ht (w . I CJ ld 1/ 1e,0 <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 ey'�lnc,�vtytiiroonmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail 'v 1 -fit the same time it is <br />provided to me or my representative. PA�cI�/FD <br />TYPE OF SERVICE REQUESTED: S�no b / <br />COMMENTS: <br />J UN <br />SAN", COUNTY <br />ENVIFIONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />E q& <br />qC1 <br />DATE: _0-5 <br />ASSIGNED TO: <br />EMPLOYEE #: j I] ® <br />u <br />DATE: <br />--TF/-E <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />g <br />: <br />Fee Amount:z a <br />Amount Paid <br />a -� - <br />Payment Date L j�/C <br />Payment Type I f' <br />Invoice # <br />Check # 9 7 <br />Received By <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />} £ >"'A4, <br />