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SAN JOAQU*COUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />BYM(_ <br />B 3 ESS NAME <br />Y �' t? y C�t'� �i' C + <br />FACILITY ID # <br />P E# C� EV. <br />j , �. <br />131 <br />SERVICE REQUEST # <br />ASSIGNED TO: <br />FAX#. <br />1C) - s 9-6 <br />STATE( zlP�lnn, A3f <br />/ JJ � <br />SERVICE oDE: <br />P 1 E: Z O <br />; <br />Amount Paid <br />— <br />Payment Date O <br />Payment Type ✓ <br />invoice # <br />ER/ OPERATOR <br />Received By:% <br />J <br />CHECK if BILLING ADDRESS <br />FAaLITY NAMEAl <br />/ <br />tff <br />.?�( <br />SITE ADDRESS <br />v, <br />� <br />.„,C <br /><_ <br />t<cer ra <br />Street Number <br />Direction <br />Street mecityZi <br />Code <br />HOME or MAILING ADDRESS (If Different from Site//Ayyddress) <br />&r ;.5*'ip., �, y� p� "9V e -p <br />VQ <br />Street Number <br />Street Name <br />CITYSTA <br />zip <br />PHONE #1 <br />Exr. <br />APN # <br />LAND USE APPLICATION # <br />(20 ` 2 <br />PHONIER <br />Exr• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE,9 STOR <br />yr r f� , l' /�� <br />K <br />CHECK if BILLING ADDRESS <br />BYM(_ <br />B 3 ESS NAME <br />Y �' t? y C�t'� �i' C + <br />P E# C� EV. <br />j , �. <br />131 <br />1-17o11djduwaADDRESS <br />ASSIGNED TO: <br />FAX#. <br />1C) - s 9-6 <br />CITY P �, <br />STATE( zlP�lnn, A3f <br />/ JJ � <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, STA <br />Ad FERE laws. �f <br />APPLICANT'S SIGNATURE: %'2 DATE: <br />PROPERTY/ BUSINEss OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT a r <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or eny assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail t �®TIe time it is <br />provided to me or my representative. – n <br />TYPE OF SERVICE REQUESTED: ?' <br />COMMENTS: <br />v <br />JUN 2 12004 <br />- _ SAN JOA01AN COl/NTY <br />/ <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Compl (if already completed): <br />SERVICE oDE: <br />P 1 E: Z O <br />Fee Amount:2 <br />Amount Paid <br />— <br />Payment Date O <br />Payment Type ✓ <br />invoice # <br />Check # (q' <br />Received By:% <br />1V A <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />