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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Ty of Business or Property <br />FACILITY ID # <br />SERVICE RE <br />Q <br />(- r <br />.� <br />CL3m) q q& <br />S Co yl? <br />�i OMMENT <br />O ERIOPERA11711M <br />STATE(1 Z!P <br />CHECKIf BILLING ADDRESS <br />1TOR <br />0 <br />od <br />00 N <br />FACILnr <br />G <br />SAN JOAQl11NENT <br />SITE ADDRESS 19i11g <br />I <br />''-tiPPROVED BY: <br />MPLCYEc #:±i <br />VStrset Number <br />DI on <br />(Street Name <br />Date Service Completed (if already completed): <br />`'N" <br />SERVICE CODE: <br />P 1 E: '2- <br />Fee <br />Fee amount: <br />Amount Paid a ?t?. �� <br />Payment Date <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Payment Type L/ <br />invoice <br />Check # g <br />Re eived By: <br />Street Numhar <br />Street Name <br />CITY <br />STATE Z!P <br />PHONE #1 <br />ENT. <br />APN # <br />LAND USE APPLICATION # <br />06q) 4 0 <br />1 <br />PHONE#2 <br />EXT. <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME ; I <br />Q <br />(- r <br />P Elm <br />HOME or MAILING ADD R S <br />FAX # <br />C7L. <br />CITY „ <br />STATE(1 Z!P <br />)5 <br />ATH <br />BILLING A KNOWLEDGEMENT: 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDRML laws. <br />— APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUsiNESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT ks not theBmLWGPARTY, 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 />14 200 <br />� AN <br />00 N <br />SAN JOAQl11NENT <br />NVIRO <br />''-tiPPROVED BY: <br />MPLCYEc #:±i <br />EMPLOYEE* � <br />DATE: <br />ASSIGN63 TO: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: '2- <br />Fee <br />Fee amount: <br />Amount Paid a ?t?. �� <br />Payment Date <br />Payment Type L/ <br />invoice <br />Check # g <br />Re eived By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />"a <br />0 <br />