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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# E <br />SERVICE REQUEST # <br />FAx# <br />( ) <br />CITY STATE C— AZIP / 2 l <br />CCUN <br />MfgL <br />W E <br />DE H� <br />OWNER / OPERATOR <br />EMPLOYEE #: <br />f7ti LA i <br />Y) <br />CHECK If BILLING ADORESSO <br />FACILITY NAME l <br />DATE: C) -3--22_Date <br />Service Completed (if already completed): <br />SITE ADDRESS I f- f <br />yr T <br />1`�t�//� <br />Fee Amount: ( _ <br />1-O <br />�/j (r/,t�1 n <br />�O <br />`6, rZLI t0ode <br />5✓treet Number <br />Direction 1/ <br />e Namd a. <br />+ Cit <br />Received By: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />AAA <br />, \ \ <br />�J <br />()rot h (> <br />� C <br />Street Number <br />SerName <br />CITY <br />Ril (7IA <br />STATE ZIP <br />PHONE #t t EXT. <br />APN # <br />LAND USE APPLICATION # <br />ATS) `- — <br />PH NE#2 En. <br />( ) —110 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />r " CHECK If BILLING ADDRESS <br />W <br />BUSINESS NAME .11 c <br />PHONE# E <br />HOME or MAILING ADDRESS I <br />FAx# <br />( ) <br />CITY STATE C— AZIP / 2 l <br />BILLING AC WLEDGEMENT: 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 <br />or 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 FEDE L laws. ISS <br />APPLICANT'S SIGNATURE: DATE: (� `� 2�' <br />/ ( — — <br />PROPERTY/ BUSINESSOWNER❑ OPERATOR/ MA; GR ❑ OTHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PAR TP 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 t0 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. AAYAIr_ <br />TYPE OF SERVICE REQUESTED: C <br />y(JL.L� R�" "i <br />COMMENTS: <br />OCT <br />0 <br />1 2U?7 <br />QU/N <br />CCUN <br />MfgL <br />W E <br />DE H� <br />ACCEPTED BY: C -r-^ <br />1 Vj_ <br />EMPLOYEE #: <br />DATE: O - 5-�Z <br />ASSIGNED TO: ) `• _.l S <br />EMPLOYEE#: <br />DATE: C) -3--22_Date <br />Service Completed (if already completed): <br />SERVICE CODE: <br />P/E: D <br />Fee Amount: ( _ <br />Amount Paid <br />b� <br />Payment Date �b ?Z <br />Payment Type A <br />Invoice # <br />Check #f 5 (���&j� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />P(�'6"�-Qiz 5 <br />