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1t <br />SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTH40EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# EXT. <br />SERVICE REQUEST # <br />Ga5CL.11,:C Sr�rT►��, :a <br />-%3D <br />ACCEPTED <br />Sao �3?o � <br />EMPLOYEE #: <br />DATE: C 11 <br />ASSIGNED TO: <br />OVVNER i OPERATOR <br />EMPLOYEE #:DATE: <br />V� 'LeIZC` 6 -?'U = IZt'�' 1 F -N Z ' ix L'- C' I, —e i\ <br />CHECK If BILLINGADDRE <br />FACT ITY NAME <br />SERVICE CODE: 1 E: <br />Fee Amount: <br />SITE ADDRESS <br />121 c <br />Payment Datel <br />N t�-t N E � �N � <br />Invoice # <br />� � cx>✓�.-r� ►..� <br />q � a. ► <br />Street Number <br />Direaion <br />Street Name <br />city <br />Zin Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />U, bl� 4I v- re- eI Street Number <br />Street Name <br />CITY <br />JA �\t'1Pbe.1-) <br />STATE ZIP <br />0 A <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />((;SI ) ( 9 - -; ZCI 1 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX# <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FE L laws. �j / g <br />APPLICANT'S SIGNATURE ~f�Z DATE: ( ( G ' <br />PROPERTY / BUSINESS OWNERLI OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AG N <br />If APPLICANT is not the BILLING PARTY proof of authorization to Sign is req red 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 />1_atr . r <br />�r <br />COMMENTS: ( <br />. ,� oL(. (- ,_ - <br />J <br />ci �, c3 C_ <br />a <br />JUL 19 2011 <br />SAN JOAQU <br />ENVIRONMEONOTAL TY <br />HEALTH DEPARTMENT <br />ACCEPTED <br />EMPLOYEE #: <br />DATE: C 11 <br />ASSIGNED TO: <br />EMPLOYEE #:DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 1 E: <br />Fee Amount: <br />Amount Paid GG _ <br />Payment Datel <br />Payment Type <br />Invoice # <br />Check #S Ogfq <br />Re eive By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />