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+' SAN JOAQUIN _ JUNTY ENVIRONMENTAL HEALTH L ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Is <br />� <br />D <br />CHECK IT BILLING ADDRESS <br />FACILITY ID # <br />U <br />SERVICE REQUEST # <br />S(L 00S►qqe) <br />OWNER/ 4PERATOR <br />(j (� j, <br />BUSINESS NAME <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />PHONE # EXT, <br />- <br />0659 CA <br />HOME or MAILING AD SS <br />SITE ADDRESS <br />Street Number <br />re <br />1 ., <br />111 <br />C <br />111 CI <br />Cade <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />SERVICE CODE: Z"3 <br />STATE zip <br />PHONE #1 EXT. <br />-7 U -t <br />APN # <br />3(�/--� <br />LAND USE APPLICATION # <br />PHONE #2 E". <br />1 <br />Payment Type <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />� <br />D <br />CHECK IT BILLING ADDRESS <br />COMMENTS: <br />t <br />BUSINESS NAME <br />ACCEPTED BY: <br />C�c.v <br />l- <br />PHONE # EXT, <br />- <br />0659 CA <br />HOME or MAILING AD SS <br />DATE: <br />FAX# <br />; Y� <br />EMPLOYEE#: <br />c , 3q— 0362 <br />CITYSTATE <br />Elate Service Completed (if already completed): <br />zip ITS»+ <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTEI DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as ' entified on this form. <br />I also certify that I have prepared this applicall and that the work to be perforated will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE d FEDE la <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPER OR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br />IfAPPLICANT is not the BILL NG PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE IN ORMATION: When applicable, 1, 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 HEALT11 DEPARTMENT as soon as it is av4" same time It is <br />provided to me or my representative. �l�z�"l�l ry� �� <br />TYPEOFSERVICE REQUESTED: <br />COMMENTS: <br />020 <br />SAN JOAQUIN COU <br />IEWRONTY <br />HEALTH DEPARjIWENT <br />ACCEPTED BY: <br />C�c.v <br />l- <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />; Y� <br />EMPLOYEE#: <br />DATE:2—'�(l_ <br />Elate Service Completed (if already completed): <br />SERVICE CODE: Z"3 <br />1 PIE: (0 01 <br />Fee Amount: <br />-7 U -t <br />Amount Paid <br />3(�/--� <br />Payment Date �2 (21j <br />2Q <br />Payment Type <br />Invoice # <br />Check # ` <br />Re <br />Recelved By: <br />48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />