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SAN JOA# COUNTY ENVU*ONMENTAL HEAL EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/rn <br />,' /� <br />W KK��P r <br />CHECK if BiLLIN AD RESsW <br />FACILITY ID # <br />fi ' T <br />SERVICE REQUEST # <br />'„; <br />I <br />HOME Of Mmtlk <br />1316 3 / 6 <br />ASSIGNED TO: <br />tZ60 315 /7 <br />OWNER i OPERATOR <br />CITY �p <br />Date Service C mpleted (If already completed): <br />CHECK if BILLING ADDRESS <br />Q � <br />� <br />Fee Amount: <br />FACIL NAME= <br />o o <br />li u- n I''-5 <br />Payment Date <br />y -1 D Y <br />SREADD I2, <br />C <br />b -Aa y�l°r%� <br />� <br />Received By: I-Z� <br />QG�Y�� <br />ZU <br />Street Number <br />Direction <br />Name <br />c1tvZi <br />Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Stmt Number <br />treat Name <br />CITY <br />STATE zip <br />PHONE #1 <br />EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQSTOR <br />` <br />/rn <br />,' /� <br />W KK��P r <br />CHECK if BiLLIN AD RESsW <br />BU I ss NAME <br />fi ' T <br />C -0r.! FIVE IJ <br />� % .�i�l� di � '� find rK. � pPR 7 2004 <br />SAN JOAQUIN COUNTY <br />ENVIR tlElJTAl- <br />PHONE # rr� <br />v J <br />I <br />HOME Of Mmtlk <br />1316 3 / 6 <br />ASSIGNED TO: <br />(� l <br />7 EMPLOYEE #: <br />CITY �p <br />Date Service C mpleted (If already completed): <br />STATE ZIP <br />130 <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, 2M2 <br />laws r��) <br />APPLICANT'S SIGNATURE: DATE:” <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AU ORmEDAGENT <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 my representative. n <br />TYPE OF SERVICE REQUESTED:&i <br />C T <br />COMMENTS: <br />C -0r.! FIVE IJ <br />� % .�i�l� di � '� find rK. � pPR 7 2004 <br />SAN JOAQUIN COUNTY <br />ENVIR tlElJTAl- <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: H <br />ASSIGNED TO: <br />7 EMPLOYEE #: <br />DATE: <br />Date Service C mpleted (If already completed): <br />SERVICE CODE: C <br />P / E: <br />Fee Amount: <br />Amount Paid 1�7;177 q v 0 <br />Payment Date <br />y -1 D Y <br />Payment Type ✓ <br />Invoice # <br />Check # 0 -Lt of <br />Received By: I-Z� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />