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•7A1�I ,J VAl1Ul1V:V U1V 1 Y 1`i1V V 11iV1V1V1L' 1V 1HL I1L' HLlllr.l'AKl 1V1L' 1V 1 <br />SERVICE REQUEST <br />Ty f Busines or Pro erty <br />FACILITY ID # <br />,Orr -)o ll/l. Jt <br />SERVICE REQUEST # <br />PAYMENT <br />BUSINESS NAME <br />_ <br />PHONEA j j ^ EXT. <br />I —IY <br />HOME or MAILING ADDRES t <br />OW <br />OW R / OPERAT ter' <br />t <br />CHECK If BILLING ADDRESS ❑ <br />FACILrr NAME 49 <br />ZIP <br />SITE ADDRESS <br />I <br />Lbt�e <br />T95,?,140 <br />Street Number <br />D"e an <br />city21 <br />Code <br />HOME or AILING ADDRESS (If Different om <br />Site Address) <br />EMPLOYEE #: <br />Street Number <br />Date Service Completed (if already completed); <br />Street Name <br />CITY <br />r <br />00- STATE ZIPq4,5 <br />PHONE #1 E.T. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Payment Type _.- - <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICI-tEQUESTOR <br />REQUESTOR ` 4 , ', - <br />(7 ( Q <br />, <br />CHECK if BILLING ADDRESS <br />,Orr -)o ll/l. Jt <br />PAYMENT <br />BUSINESS NAME <br />�I ' <br />l� <br />PHONEA j j ^ EXT. <br />I —IY <br />HOME or MAILING ADDRES t <br />+� <br />FAX # � n j ?)q <br />t <br />Y� C� 6 <br />CITY <br />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 or <br />activity, will be billed to me or my business as identified on this form. <br />I also certify that I have prepared thisp lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard S ATE and FEDERAL laws. <br />r - <br />APPLICANT'S SIGNATURE: DATE:IP2 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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 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 rhy representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />OCT2 4Z002 <br />SAN UIN COUNTY <br />BLI✓°HEALTH SERVICES <br />ENVIRONMENIKI HEALTH DIVISION <br />APPROVED BY: <br />EMPLOYEE #: ' rI <br />(- <br />DATE: <br />t Ir <br />ASSIGNpD TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed); <br />SERVICE CODE: <br />P / E: <br />Fee Amount: 4- <br />Amount Paid <br />ab -7 <br />Payment Date <br />Payment Type _.- - <br />Invoice # <br />Check # <br />Received y: <br />EHD 48-01-096 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />