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SAN JOAQUINIOUNTY ENVIRONMENTAL HEALTH 16ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME c <br />(r UJL C <br />FACILITY ID # <br />SERVICE REQUEST # <br />) <br />CITY p STATE /,+ ZIP <br />5koo- -7 q� <br />052017 <br />SAN YiAQUry�a <br />DEpOTMEA? <br />NER / O� <br />\ FER TOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />(J^i <br />ASSIGNED TO: C CfA l 1 <br />SITE ADDRESS l (i1Vi <br />DATE: <br />Date Service Completed (if already ompleted): <br />s` (" <br />T(7 b <br />Street Number <br />ct-io. <br />Direction <br />Str et Name <br />Cit <br />Zi Code <br />Payment Type l7 <br />Invoice # <br />Check # 5-R 1/ <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(61 �q'l _'3 <br />3 111 <br />be <br />PHONE #2 EXT. <br />( ) <br />BOS DIS,�TR__IC^^T <br />VV <br />LOCATION CODE <br />v <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR < CHECK If BILLING ADDRESS <br />w <br />BUSINESS NAME c <br />(r UJL C <br />PHO,,.,, <br />�U �. ExT. <br />HOME or MAILING Mes au c&`�Ax <br />(9� 0% <br />) <br />CITY p 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 or <br />activity will be billed to me or my business as identified on this form. <br />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: (�4,1r1�� UJ> DATE: �,�, J�� <br />PROPERTY / BUSINESS OWNER [3OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ULI t aC`�� <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />AYMEN <br />COMMENTS: <br />ED <br />MAY <br />052017 <br />SAN YiAQUry�a <br />DEpOTMEA? <br />ACCEPTED BY: M�� <br />EMPLOYEE #: <br />DATE: T / 7 <br />ASSIGNED TO: C CfA l 1 <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already ompleted): <br />SERVICE CODE: 19% <br />P I E: oZ?�o <br />Fee Amount: r� ` <br />Amount Pal �z d� <br />Payment Date <br />S/7 <br />Payment Type l7 <br />Invoice # <br />Check # 5-R 1/ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />