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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH I)EPARTM-ENT <br />. SERVICE REQUEST <br />Type of Business or Property <br />F <br />` 1 <br />FACILITY ID # <br />3?�c <br />BUSINESS NAME! <br />SERVICE REQUEST # <br />s21� <br />OWNER / OPE OR <br />DATE: ( & l f r <br />HOME or MAILING ADDRESS <br />1 <br />CHECK if BILLING ADDRESS D <br />FACILITY NAME <br /># nq. <br />CITY <br />SERVICE CODE: �� <br />SITE ADDRESS <br />Street Nufnber <br />Direction <br />re tN.; <br />Payment Date <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Check # ' C (0=1 <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />ExT. <br />APN # <br />LAND USE APPLICATION # <br />PH #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />n�_ <br />` 1 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME! <br />ACCEPTED BY: G LI VF—" <br />EMPLOYEE #: U � Z_-( <br />DATE: ( & l f r <br />HOME or MAILING ADDRESS <br />I <br />DATE: 3 t ( C'( it <br /># nq. <br />CITY <br />SERVICE CODE: �� <br />STATE ZIP <br />I <br />— <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 t -application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standa ,�ATkand FEDERAL s. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ THER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BIL1JNGPARTY 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: �,tS f b <br />PAYMENT <br />COMMENTS: <br />MAR 16 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: G LI VF—" <br />EMPLOYEE #: U � Z_-( <br />DATE: ( & l f r <br />ASSIGNED TO: 7 -P -4--J <br />EMPLOYEE #: 2-6416 <br />DATE: 3 t ( C'( it <br />Date Service Completed (if already completed): <br />SERVICE CODE: �� <br />P I E: .:2-2 L) J' <br />Fee Amount: '6 & , <br />Amount Paid 3 <br />Payment Date <br />Payment Type L/ <br />Invoice # <br />Check # ' C (0=1 <br />Received By: <br />EHD 48-02-025 �fOlfVlloldn.Rod)' `` <br />REVISED 11/17/2003 <br />