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SAN JOAQU*OUNTY ENVIRONMENTAL HEALPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />T ,G► I U !��in/Il 5e"ruI C.e <br />FACILITY ID # <br />HOME O AILING A DDDD ES$ 1.fi`�� & <br />SERVICE REQUEST # <br />blvd bC <br />LA 66AO$i$ <br />OWNER /,qPERATORCHECKif <br />�CT 14�IL <br />BILLING ADDRESS <br />NTY <br />FACILRYN <br />m 0� <br />ACCEPTED BY: <br />EMPLOYEE #: <br />SITE ADDQRE Sr� <br />a x -m <br />q <br />l� r l p <br />1 <br />9jrL 3 f <br />DU Street Number <br />rection <br />Name <br />C <br />7ip Code <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />HOME or U ADWSS Diffe <br />Fit from Site Address) <br />Check # �`� <br />,y <br />7 <br />Street Number <br />Street Name <br />CITY\ „ I� <br />V <br />n <br />(� <br />$TATE P <br />PHONE #1 <br />E.T• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />b h I n I pa u v✓1 A/ n CHECK If BILLING ADDRESS <br />((JJ <br />BUSINESS NAME <br />T ,G► I U !��in/Il 5e"ruI C.e <br />PHO 3, -7.2 -.�o7 3 EXT. <br />HOME O AILING A DDDD ES$ 1.fi`�� & <br />X# � <br />()A <br />TATE ZIP <br />CITY V\ I . 5o O -D 0A 95Z7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 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: /� ��1 / <br />PROPERTY / BUSINESS OWNER ❑�OPE MANAGER 13 OTHER AUTHORIZED AGENT 16 (_.61 / Tr0 <br />If APPLICANT is not the BILLING PARTS 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 />COMMENTS: <br />�CT 14�IL <br />NTY <br />ACCEPTED BY: <br />EMPLOYEE #: <br />a x -m <br />q <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # �`� <br />,y <br />Recei4ed BtIA / <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />