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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID If <br />BUSINESS NAME <br />SERVICE REQUEST # <br />Teo. sh op <br />ExT• <br />�S6�o s A LI,, <br />EMPLOYEE #: b <br />c0i`�y I <br />OWN /OPERATOR <br />HOME or MAILING ADDRESS <br />EMPLOYEE <br />Phot w, ro lt,e — <br />v haw. <br />CHECK if BILLING ADDRESS® <br />FACILITY NAME <br />73ObeY '+G0. <br />Pit: <br />l�0/ <br />ADDRESS <br />W <br />y�/� <br />I ' IQYC��•� <br />t� % o %Z <br />ej �pC/G ` <br />CrSZU �- <br />nSITEE <br />—15-1 Street Number <br />Dlrectlon <br />Street Name <br />City <br />Zip C.de <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 En. <br />APN # <br />LAND USE APPLICATION # <br />( 209) t4l-c -q u <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR AL,�, <br />1. J; , 1M _' <br />t„� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />��� <br />PHONE# <br />ExT• <br />�S6�o s A LI,, <br />EMPLOYEE #: b <br />zw <br />�c�o�loza <br />HOME or MAILING ADDRESS <br />EMPLOYEE <br />FAX# <br />Date Service Completed (if already comPiet <br />SERVICECODE: 'l <br />Pit: <br />l�0/ <br />CITY s"f"Cex <br />STATE CP <br />ZIP o1r5'21'L <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 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, Standard STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ( DATE: <br />r / / <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IAI A*8.,-- <br />s <br />IJAPPL/CANT is not the BLLLlNC 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at tht Tor5� <br />provided to me or my representative. 1 ,■,�-,- <br />TYPE OF SERVICE REQUESTED: P14R N ],ne-Cj�- <br />COMMENTS: <br />_ (`I <br />Cx Vtd1r�� �I�'LI I <br />��� <br />N <br />SAN JOAOUIN CO <br />ENVIRONMENT <br />HEALTH DEPART <br />ACCEPTED BY: � a c � <br />EMPLOYEE #: b <br />DATE: I ;0,21 <br />ASSIGNEDTO: vf a <br />EMPLOYEE <br />DATE: rl / <br />Date Service Completed (if already comPiet <br />SERVICECODE: 'l <br />Pit: <br />l�0/ <br />Fee Amount: Amount Paid <br />Payment Date <br />t� % o %Z <br />Payment Typer-l�Invoice <br />If <br />Check # Z Z <br />Received By: PIVY <br />EHD SED 11/1 n�� qvl 1 SR FORM (Golden Rod) <br />REVISED 11/17/2003 ./,V/ V I <br />)NTY <br />IENT <br />