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SAN JOAQUIN (:OUNTY ENVIRONMENTAL HEALTH ADEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />LTA S `_ (-a <br />FAX# <br />( ) 5/ - RZy <br />CITY <br />Cr V2 <br />S <br />5 - �g (,-, z' <br />Jul 2 12) 2009 <br />ENVIRONMENT HEALTH <br />OWNER /OPERATOR 4 <br />PERM TISEMCES <br />E] <br />I -e <br />ll <br />EMPLOYEE #: <br />CHECK If BILLING ADDRESS <br />FAauTY NAME <br />DATE: 2-2 / <br />ASSIGNED TO: �.rt S <br />EMPLOYEE #: <br />SITE ADDRESS ,�/ /� <br />k s <br />� f� e� / _ 1 <br />C�-/lJ <br />Date Service Completed (if already completed): <br />C l C K� <br />J`�} <br />SERVIC`E,FCODE: <br />9's <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Payment Type <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />( <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />I <br />I C tLf- ©30--r2- <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />2 <br />LOCATIO{J CODE <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />l`)) ►►► 111 111 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME ��. __// t <br />PHONE# _ / EXT. <br />HOME or MAILING ADDRESS�� �� Lrd AVS <br />FAX# <br />( ) 5/ - RZy <br />CITY <br />Cr V2 <br />STATE ZIP <br />�'q �'SQ ,L - <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: -1126169 <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT OO ,n LU pi -e V — a!�2 rNff– <br />If APPL/CANT 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: (� S j <br />(�'i9 f <br />COMMENTS: <br />1:1 Lui <br />Jul 2 12) 2009 <br />ENVIRONMENT HEALTH <br />PERM TISEMCES <br />ACCEPTED BY: Q v I�f <br />EMPLOYEE #: <br />03 Zr <br />DATE: 2-2 / <br />ASSIGNED TO: �.rt S <br />EMPLOYEE #: <br />L�(�,.�� % <br />C7 <br />DATE: 717-74 <br />-7 0 <br />Date Service Completed (if already completed): <br />SERVIC`E,FCODE: <br />q fi' <br />P <br />Fee Amount: 4 3 (s" �� <br />Amount Paid 3) <br />Payment Date <br />/ <br />Payment Type <br />Invoice # <br />Check # <br />( <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />