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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property I��c�v`�c� FACILITY ID # BUSINESS %TAME SERVICE REQUEST # �as� c�Kc 7 e rti�� -� Exr. � � (-� HOME Or MAILING ADDRESS S i.�.; � � (,,' r 1 � ,r . JL4 � } �' � EMPLOYEE #: S � C�0�2�3 OWNER / OPERATORS S � �ry � �q � � r \ � � � CHECK If BILLING ADDRESS ❑ FACILITY NAME r_�C��V�S �, C T � O DATE: i Ol4 / � p�v V�/ ��. ��12L � 1 SITE ADDRESS � � � Street Number r, (� Direction �Y�� L � Street Name P 1 E. � ba �0�1�V`�O p Cit 1 S' Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) 5a ---' •# Payment Date � 2-� Payment Type Invoice # Street Number Street Name CITY Received By: $TATE ZIP PHONE #1 Exr. APN # LAND USE APPLICATION # PHONE #Z ( ) ExT• BOS DISTRICT � \ LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR 1Jc�ni I��c�v`�c� CHECK If BILLING ADDRESS BUSINESS %TAME L� [vim. :SL f U t C.� �CS'gN f _ 1 �LT/�/ pgWNTq� �i t� ��i1��1�YL: ��lpt��t 1�'NT , yys��ri^ -� b�P yv�,o,t��. �/e �'Pvi �lor' F�i�c� �F' %J r/Jr;�?iG� yl?f�f S�}�C�rG�,�" t-br,n'► �� Sf%p��C � Jn5 FG�ipY' _` �� ,.,�,-� �'�Jl�' YP �,��Pt',r� PH�O7�N.E� # aW`I' Exr. � � (-� HOME Or MAILING ADDRESS S i.�.; � � (,,' r 1 � ,r . JL4 � } �' � EMPLOYEE #: FAX # ( ) �' 'v CIN /l,{ d r l O (r(� (U $TATE C ZIP � ��' �� J BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar ATE an D laws. APPLICANT'S SIGNATURE: � � DATE: (� .� � v20�� PROPERTY /BUSINESS OWNER OPERA OR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tirte AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of � ��j�ted at the above site address, hereby authorize the release of any and all results, geotechnical data and/or en �C�aIUVc,''tL�� l[�assessment information to the SAN 10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availab)te and at trig 9r�� time it is provided to me or my representative. �'"�•�o C y �n�_ TYPE OF SERVICE REQUESTED: �OgQUt COMMENTS: f1�,// I � � (� Ivl�z tj�u � Si �� t��(' �e �ui rz �� -s � (�� > 1_ � U✓tS . S 4' p�'I c �i,��tt-G'l �%PPG�-�o��'n��Grr ctrPr� �-"lc��-�� �o res S-�$-f'PYt't� �C� f � d G�9 r?`S`�—�%� � " �CS'gN f _ 1 �LT/�/ pgWNTq� �i t� ��i1��1�YL: ��lpt��t 1�'NT , yys��ri^ -� b�P yv�,o,t��. �/e �'Pvi �lor' F�i�c� �F' %J r/Jr;�?iG� yl?f�f S�}�C�rG�,�" t-br,n'► �� Sf%p��C � Jn5 FG�ipY' _` �� ,.,�,-� �'�Jl�' YP �,��Pt',r� ACCEPTED BY: �-� �i�� EMPLOYEE #: DATE: �U/� I �� ASSIGNED TO: � iTJ EMPLOYEE #: DATE: i Ol4 / � p�v Date Service Completed (if already completed): SERVICE CODE: � (� I P 1 E. � ba Fee Amount: ��'� Amount Paid 5a ---' •# Payment Date � 2-� Payment Type Invoice # � 23 Z� t6 Received By: - . vV i v n v EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 ._