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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE # EXT. <br />FACILITY ID # <br />FAX # <br />SERVICE REQUEST # <br />GW6 <br />/"7 <br />EMPLOYEE#: r/I <br />DATE:2 <br />ASSIGNEDTO: Lem <br />OWNER / OPERATOR <br />EMPLOYEE#: <br />1 <br />CHECK if BILLING ADDRESS <br />SERVICE CODE: D / <br />P 1 : ` 3 <br />Fee Amount: f S <br />FACILITY NAME <br />I Payment Date <br />Payment Type <br />SITE ADDRESS <br />` <br />C4✓17 p , nIC? S' <br />l� ' ' I <br />L <br />�77y-� P'Lp„ I <br />(r/✓Cit✓/ V/V <br />Cf 3 <br />Str¢et Number <br />Diredlon <br />Streetl N55me <br />ZI Code <br />HOME r MAILING ADDRESS (If Different from Site Address.) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP 1/1- <br />5-120 <br />PHONE 41 <br />v <br />Ex . <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />Ems. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <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 <br />or activitywill be billed to me or my business as identified on this form. <br />I also certify that I have prepared this applic [ion and that the work t0 be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, 'TA d FEDGRAL laws. j�'' <br />APPLICANT'S SIGNATURE: DATE: 1376 3 D3 <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPL/CANT is not the BILL/NG PAR IY 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 the same time it is <br />provided to me or my representative. PAVAAM&z . <br />TYPE OF SERVICE REQUESTED: MSCAAoAun <br />RECElyzir <br />COMMENTS: �'„ <br />/ti'" /t� <br />i� 1au'v 0 <br />r <br />MAR <br />13 2U2 <br />ENVIRONMENTAL <br />HEALTH DEPARTMEN <br />ACCEPTED BY! <br />/"7 <br />EMPLOYEE#: r/I <br />DATE:2 <br />ASSIGNEDTO: Lem <br />EMPLOYEE#: <br />DATE:3 I �� <br />Date Service Completed (if already completed): <br />SERVICE CODE: D / <br />P 1 : ` 3 <br />Fee Amount: f S <br />Amount Paid l __ <br />I Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />IReceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />