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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH. DEPARTMENT <br />6 SERVICE REQUEST 0 <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />- 4- <br />HOME or MAI NG DDPESS <br />OWNER/ OPE OR <br />RECEIVED <br />(l <br />CHECK If BILLING ADDRESS <br />GAle la <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SER ICES <br />FAC ITY NAME <br />v V "'� S �'� <br />cN <br />FN! HfA!.,hi L IVI ;i1iv <br />SITE ADDRESS <br />'1 —25-7'5—Street <br />` C,,, -k7IL <br />I 8 <br />DATE: ._ <br />--79 <br />�( G C� <br />r 3? <br />Number <br />Direction <br />DATE: 7 ,3 •- 0 <br />Street Name <br />Ci J <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: <br />Amount Paida� <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHOON�E#1 EXT• <br />( (J" (, l) / <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT11 <br />L OCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />n `n \ CHECK If BILLING ADDRESS <br />CL t V (i(�J � iA- <br />Bus E S E <br />PH # i I g ExT. <br />fb <br />HOME or MAI NG DDPESS <br />FAX # <br />ITY STATE Zip <br />k3 ` <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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: <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 my representative. <br />TYPE OF SERVICE REQUESTED: <br />S <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JUL 0 3 2002 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SER ICES <br />cN <br />FN! HfA!.,hi L IVI ;i1iv <br />APPROVED BY: <br />EMPLOYEE #: 2Z �% <br />DATE: ._ <br />ASSIGNED TO: <br />EMPLOYEE M-3 b (� <br />DATE: 7 ,3 •- 0 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: C <br />P 1 E: <br />Fee Amount: <br />Amount Paida� <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # T'ZrI' <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />