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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH WARTMENT <br />SERVICE REQUEST <br />Type of Buaiaen <br />or Property <br />a• <br />CHECK If BILLING 6206#SS <br />FACILITY 10 # <br />SERVICE REQUEST <br />6rdCerS <br />S+err C <br />EMPLOYEE #:( j Z <br />3f.Z <br />) 97 d `1 <br />-# <br />1,SR 00 5(e, / <br />OWNER /OPERATOR <br />zip 9z5 -0i <br />CHECK If BILLING <br />Data Service Completed (if already Completed): <br />JI 1 z L -J'eS4J rP7 <br />Gre f � rS <br />ADDRESS© <br />FACIuTY NAME <br />Fee Amount: 4� 515, , <br />Amount Paid <br />3�s, v a <br />Payment Data 319-1017 <br />SITE ADDRESS <br />Invoice # <br />n <br />C L I <br />Received By:� <br />/� C <br />U <br />Street Number <br />Diw <br />r 1 a <br />N an* <br />ty <br />Zia <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE LP <br />PHONE #1 <br />( ► <br />ExT• <br />APN # <br />l c, / - <br />2t o --t,/ <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �� <br />C� 10-4 <br />7 <br />. &F t 7— <br />a• <br />CHECK If BILLING 6206#SS <br />BUSINESS NAME <br />J-3 C�'11i1 �✓ttW1o/l�c� <br />PHONE # <br />Qc <br />ET• <br />5i7-- 9-10 2 <br />HOME or MAILING ADDRESS <br />9oF,5 k-ri I ss,�✓t g2,, z /� t - P►�-t g 8 <br />EMPLOYEE #:( j Z <br />FAx # <br />(q:%'1 <br />) 97 d `1 <br />CITY le J,-0 (.6 1 <br />STATE e ,t <br />zip 9z5 -0i <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, S TE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINEss OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENVKJ t'�+S l -VI -i �T 1dt -0 <br />If APPLICANT is not the B/LLING 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 avai)a a alyd.f"e time it is <br />provided to me or my representative.\L/ F f 7 <br />TYPE OF SERVICE REQUESTED: �{ S � <br />. &F t 7— <br />COWAENTS: <br />MAK <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:Q j (. _I % E r 44 <br />EMPLOYEE #:( j Z <br />DATE: 7- G+ <br />ASSIGNED TO: ,rv1 �� <br />EMPLOYEE #: ! 4f C- k <br />DATE: 6 <br />Data Service Completed (if already Completed): <br />SERVICE CODE: / �% <br />P /E: <br />Fee Amount: 4� 515, , <br />Amount Paid <br />3�s, v a <br />Payment Data 319-1017 <br />Payment Type <br />Invoice # <br />Check # ' To IF S <br />Received By:� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />