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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME / r � I <br />1�� V <br />SERVICE REQUEST # <br />GDF <br />Ej ` <br />6 oza)50 <br />2y <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />ACCEPTED BY: L t �� t� <br />EMPLOYEE #: CiZ <br />SITE ADDRESS 2 501 E. l it -50 <br />ASSIGNED TO:� �� L i_ <br />�,A(�Q <br />Gl r,32p <br />Street Number Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P I E: �� _ p <br />Fee Amount: S, cTz� <br />Amount Paid <br />%S <br />Payment Date <br />Street Number <br />Payment Type ✓ <br />Street Name <br />CITY <br />Re By: <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />( 24% 938 -39-1 / <br />, r-7 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION COD <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU ESTOR C /' <br />J V <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME / r � I <br />1�� V <br />PH0 E##{ EXT. <br />( �� I � — 1'7� <br />HOME or MAILING ADDRESSrr , r <br />FAX# <br />CITY f�—'ESldo <br />STATE (A ZIP 9372,1? <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 />I also certify that I have prepare is ap licat�n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Sta dards, ST TTEnd*FE E lawl. ', // <br />APPLICANT'S SIGNATURE. ` "� ()7" • 2-7.6 <br />DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT re spf--ha <br />IfAPPLiCANT 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: JZFPLAC,E 07 F1 LL <br />MV L c -S7— 10 C-'7y� O P— i j <br />COMMENTS: <br />' o <br />P �0"J <br />SPN 30P oNtf`� �MEN� <br />ACCEPTED BY: L t �� t� <br />EMPLOYEE #: CiZ <br />ASSIGNED TO:� �� L i_ <br />EMPLOYEE #: C, r� % <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: f <br />P I E: �� _ p <br />Fee Amount: S, cTz� <br />Amount Paid <br />%S <br />Payment Date <br />Ly�� <br />Payment Type ✓ <br />Invoice # <br />Check # <br />Re By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />