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SAN JOAQUIRCOUNTY ENVIRONMENTAL HEALTHOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />R,ET-A,L <br />FAX# <br />(Cfr6 1 <br />05 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />THDEPEHEALRTMNT <br />ACCEPTED BY: <br />SITE ADDRESS <br />EMPLOYEE #: <br />�'(� Q !L f4j—Q IJ[ 2 <br />ASSIGNED TO: <br />5 TO Cie 1-0 ti( <br />�j S Z O <br />Z Street Number <br />Direction <br />Street Name <br />SERVICE CODE: <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS/ (if Different from Site Address) <br />Amount Paid 3 — p <br />% S' ` v r <br />Street Number <br />Invoice # <br />Street Name <br />CITY R, c /,t,� 8 1� <br />I' �Y•• <br />STATE C ZIP G <br />/ 7 <br />PHONE#1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />r� <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I C (D(i�jL� I /ri' , <br />w Ci�y'�1 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME (� / Com. p �LLW� (` <br />� <br />PHONE # Ems' <br />qr6 3 -I r s Z <br />HOME or MAILING ADDRESS ?7. Q , 0 x f (? Z <br />C <br />FAX# <br />(Cfr6 1 <br />CITY <br />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 an that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: I / Q f-0 5� <br />PROPERTY / BUSINESS OWNER 13 OPERATOR/ MANAGER OTHER AUTHORIZED AGENT C B'�-R--/� s�( v %L <br />If APPLICANT is not the BiLLING PARTE 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. I A- '7 c I T <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />RECEIVED <br />JAN 2 2 2009 <br />SAN JOAQUIN COUNTY <br />THDEPEHEALRTMNT <br />ACCEPTED BY: <br />_ j C I <br />EMPLOYEE #: <br />DATE: Z' <br />ASSIGNED TO: <br />t C <br />EMPLOYEE #: <br />DATE: r Ut <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: 3 C; <br />Fee Amount: <br />'3 <br />Amount Paid 3 — p <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />