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F I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />9 ' SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />(/-Wo <br />0 0 D 7 a D3 <br />61COO &I q3 �L- <br />OWNER / OPERATOR <br />FAX# <br />CHECK If BILLING ADORE S <br />FACILITY NAME <br />STATE G --T— <br />ACCEPTED BY: <br />SITE ADDRESS ")Itree�t <br />/]37� <br />EMPLOYEE #: <br />�Name G( <br />ASSIGNEDTO: U ( <br />���y t1 ^, .A- <br />1� <br />N/uyber <br />Direction <br />DATE: <br />Street <br />(if already completed): <br />Cil <br />Z7 Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: 2 <br />1N <br />Amount Paid <br />4 T, I✓� <br />Payment Date <br />Street Number <br />Street Name <br />CITY <br />Check # X79 <br />STATE <br />ZIP <br />PHONE#t <br />EXT. <br />APNIf <br />LAND USE APPLICATION# <br />(-Zj5) F 3 <br />PHONE#2 <br />( ) <br />E T. <br />BQS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />IC ' <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />- <br />' <br />PHONE# ) EXT. <br />HOME or MAILING ADDRESS <br />(-P5- <br />FAX# <br />CIN <br />STATE G --T— <br />BILLING <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 a to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Cortes, Standards, TATE a d P2nE ws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/NIANAGERR OTHER AUTHORIZED AGENT❑ <br />1f 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 environmentaDsite 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: V (=J <br />COMMENTS: <br />RECEIVED <br />FEB - 9 2011 <br />SAF JOAQUIN COUNTY <br />NVIRONMENiAL <br />HEALTH DEPAATMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNEDTO: U ( <br />���y t1 ^, .A- <br />1� <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: [ <br />PIE: <br />Fee Amount: 2 <br />1N <br />Amount Paid <br />4 T, I✓� <br />Payment Date <br />Payment Type (/ <br />Invoice # <br />Check # X79 <br />Received By:-,/ ' <br />EHD 48-02-025 I !-�± SR FORM (Golden Rod) <br />REVISED 11/17/2003 j <br />1t9 VJ t J <br />