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SAN JOAQ1OUNTY ENVIRONMENTAL HEALTHQPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />PA wE 1'10 <br />FACILITY ID # <br />BUSINESS NAMEPHONE <br />Q' <br />S'CV"e- Sfe� cL�i S S vv�S TuC. <br />SERVICE REQUEST # <br />Ifo <br />EXT. <br />Z( -(0.3 e <br />HOME or MAILING ESS <br />ASSIGNED TO: � 1k L� t.T <br />5RO06-6q 12 - <br />OWNER /OPERATOR <br />CITY JOLA _ O& .. <br />E] <br />(COQ V—dJ `D 0 <br />V_P� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />P I E: Pg <br />Fee Amount: `�� <br />SITE ADDRESS <br />3 5.06 <br />Payment Date <br />� <br />Street Number <br />Direction <br />Street Name <br />-Cit <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE Zip <br />PHONE #1 ExT. <br />lac ). 3E4 . l ��.5 . <br />APN # <br />.lr� <br />LAND USE APPLICATION # <br />.:. . <br />PHONE #Z EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />'CJI. ` �-Y ►'�l� V <br />PA wE 1'10 <br />CHECK If BILLING AD DRESS <br />BUSINESS NAMEPHONE <br />Q' <br />S'CV"e- Sfe� cL�i S S vv�S TuC. <br />ACCEPTED BY: 0 L_t f _ <br />Ifo <br />EXT. <br />Z( -(0.3 e <br />HOME or MAILING ESS <br />ASSIGNED TO: � 1k L� t.T <br />FAx # <br />( OS ) <br />)-n — (oa a �P <br />CITY JOLA _ O& .. <br />STATE C& <br />ZIP Qct <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator Or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 1i0tlrly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 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: r <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT CC"E uC.P_ <br />11'APPLIC'ANT is not the BILLING PARr),, proof of authorization to sign is required Irifle <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 env ironmentaUsite 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. ( _ T , F-��— -t; <br />TYPE OF SERVICE REQUESTED: �� 1 �Sp G� <br />PA wE 1'10 <br />COMMENTS: Avo.-kcYJ-C.. 1 _ ., V La <br />� -e� c_t jjk-eu..�Es <br />a - <br />0" 2008 <br />AN JOAIQUI14 COUNN <br />BH TN DEPAR MEN1 E i'JP UE rL 14 T" R! V1 C E S <br />ACCEPTED BY: 0 L_t f _ <br />EMPLOYEE #: z7 Z r <br />DATE: ` f. o r/ <br />[ d <br />ASSIGNED TO: � 1k L� t.T <br />EMPLOYEE #: <br />I 1-E- �2- <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: / <br />P I E: Pg <br />Fee Amount: `�� <br />Amount Paid <br />3 5.06 <br />Payment Date <br />t Q <br />Payment Type <br />Invoice # <br />Check # <br />Received By: vv � <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />