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SAN JOAQUIr, )1.1NTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />.---h op i667 <br />5k 6)YERVICE REQUEST # <br />51 (.435(3 <br />OWNER/OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> h44/41.9.4 ie ipt4: <br />SITE ADDRESS <br />Street Number Direction "Ver/2 X Street Name <br />...cite: ;Oaf <br />CitY 7:3Zi3122/ <br />_ <br />HOME Of MAILING ADDRESS (If Different from Site Ad ress) <br />Street Number Street Name <br />CITY <br />STATE ZIP <br />x <br />PHONE #1 <br />EXT. APN # <br />1 -91 tj' IS <br />LAND USE APPLICATION # <br />PHONE #2 Exr. BOS DISTRICT LOCATION CODE <br />C / <br />CONTRACTOR / SERVICE REQUEST <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />BILLING ACKNO EDGEMENT: 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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br />. • RAL laws. COUNTY Ordinance Codes, Standards, STA <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER a <br />If 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 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 />nrnvided to me r my re resentative. ., . <br />TYPE OF SERVICE REQUESTED: / / el '/ 4-4 (0 PO %— <br />ReCC-NE' * <br />COMMENTS: <br />R <br />i '' <br />o' 7 n fk if% A 0 -7. 2t',3 <br />usr( nos C° pa.. <br />' 1 p34 JON— tojeg 141 <br />ACCEPTED BY: Metitalzk EMPLOYEE #: A7243 DATE: <br />ASSIGNED TO: Afa/jead EMPLOYEE #: .9.J.3 DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 6,20_ PIE: 36,6) <br />Fee Amount: I ,230( 01) Amount Paid 0 ____. Payment Date 4 I 2" ( D <br />Payment Type 1.------ Invoice # Check # i 0 1 Received By: c\a,___ <br />REQUESTOR1 <br />)orypeA if/L4 /2 <br />HOME or WiLiNG ADDRaS <br />/IV& 6/. 742 <br />CITY! 44, /0 cid e <br />491 .1_/7 /°04 <br />FAX # <br />pol )33'ia? 7 <br />STATEZ1 ZIP s• <br />13;74 331-71t <br />EXT . <br />DATE: 3-.3/-7z2 <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003