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SAN JOAQUIN NTY ENVIRONMENTAL HEALTH'ARTMENT <br />SERVICE REQUEST >. <br />Type of Business or Property <br />FACILITY ID # <br />a SERVICE REQUEST # <br />p <br />'VED <br />COMMENTS: <br />JAN 2 2 Z009 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />� <br />FACILITY NAME 1 <br />` <br />HEALTH DEPARTMENT <br />SITE ADDRESS 6b5 <br />�, <br />(CTop\ <br />V\O- <br />W <br />1�JZ lV <br />Street Number <br />Direction <br />EMPLOYEE #: <br />Street Name <br />City <br />Zio Code <br />SERVICE CODE: <br />^DATE: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: �� ~ <br />P-6 <br />Ck W (G M <br />Street Number <br />Street Name <br />CITY 1 <br />STATE ZIP 0152-40 <br />Lod <br />Check # 3 n <br />PHONE#1 ExT. ApN # <br />LAND USE APPLICATION # <br />t _JC( <br />(2(A) 3U115 <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAMEPHONE I -EXT. <br />o ( ) 1 <br />HOME or MAILING ADDRES FAX # <br />(261 410- CD <br />CIS, STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autnortzea agent ut Sallie, <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: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ur f( 1 L V V <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: <br />PAyM <br />'VED <br />COMMENTS: <br />JAN 2 2 Z009 <br />OAQUIN OUNTy <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: 12 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />'71 0r <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />^DATE: <br />P ) E: <br />Fee Amount: �� ~ <br />Amount Paid <br />3 1 S — <br />Payment <br />ate <br />2 2 0 <br />ment <br />PayType t/ <br />Invoice # <br />Check # 3 n <br />Received By: <br />EHD 4802-025 SR FORM (Gold11 en Roti) <br />REVISED 11/17/2003 <br />