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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />F CILITY ID # <br />MAIL Z 4 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SERVICE REQUEST # <br />i r <br />DATE: <br />L <br />HOME or MAILING ADDRESS <br />Sid <br />y <br />OWNER / OPERATOR ,�_ <br />( ) <br />CITY I_ <br />STATE ZIP Q <br />Payment Date <br />. t y . 7 <br />Payment Type C pp <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />^. <br />Received By: 7 <br />SITE ADDRESS <br />c <br />o (� <br />�O G��.I-V+r) <br />�s 2� 6) <br />! StreetNumber <br />Direelion <br />to / ' <br />Street Name <br />CI <br />ZI Cotle <br />HOME Site Address) <br />ADDRESS (If Different fr```o <br />'or/MAILING <br />Vi Q i? <br />��Im <br />Sheet Number <br />Street Name <br />CITY S /r - G 10 A <br />STATE !� ZIP <br />PHONE #1 <br />En. <br />APN # <br />LAND USE APPLICATION # <br />(26q)tL C1q IS <br />i <br />PHONE #2 <br />EXT. <br />BOB DISTRICT <br />LOCATION CODE <br />(Zoq ) G p 9 7 2 <br />I <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �/^ <br />V 0 <br />CHECK If BILLING ADDRESS <br />BU INESS NAME B <br />MAIL Z 4 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PHONE# ExT. <br />i r <br />DATE: <br />L <br />HOME or MAILING ADDRESS <br />DATE: <br />FAx # <br />( L <br />( ) <br />CITY I_ <br />STATE ZIP Q <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: (r p?�l/ /rjT �/� DATE: 312-q117 <br />PROPERTY I 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, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It IS provided to me or <br />my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: E20a Jc,-Q914-70k1 <br />RECEIVED <br />COMMENTS: <br />LIG � I___+I <br />MAIL Z 4 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: �n.F� <br />EMPLOYEE <br />DATE: <br />ASSIGNEDTO: I �J c� 1/Y) <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />I� <br />Amount Paid m-- <br />Payment Date <br />. t y . 7 <br />Payment Type C pp <br />Invoice # <br />Check # �—� <br />Received By: 7 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />