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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS sec e SERVICE REQUEST # CITY STATE ZIP ACCEPTED BY:iSS� � EMPLOYEE #: DATE: OWNER / OP TOR//-- S ' � � &,e-, G �A , CNECK If BILLING ADDRESS J FACILITY NAME Date Service Completed ' already completed):j SIJE ADD SERVICE CODE: �, yll�[///��1 41q PIE: � T L^CI � ' / /�SS Street Number Direction Street Nam' a Invoice # I Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY 5 f'/'C f /lJ STAYE ZIP / 2— PHONE #1 EXT. (awW OKI APN # (GySC'b LAND USE APPLICATION # PHONE #Z EXT. BOS DISTRICT ' 1 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQ STOR /J ^ ,�,/ CHECK If BILLING ADDRESS /P /40',7 / BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS sec e FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ATE and FEDERAL Ia Q APPLICANT'S SIGNATURE: �(�ii7 �� i�O DATE: J /� PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ THER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is provided t0 me or my representative. 40 A. TYPE OF SERVICE REQUESTED: S 1 -C S } C'rh (C n MPC ,' ^ COMMENTS: G(tY'ay� Ccrnec�•G� eA- ✓ s3 ^ 7� 7 + f Se , to V p'��(.. C�/1 I ti '�i,R ��18 CTjyO 4r'�F�O�N pgRT rye �Y ACCEPTED BY:iSS� � EMPLOYEE #: DATE: ASSIGNED TO: W o n EMPLOYEE #: DATE: Date Service Completed ' already completed):j Z SERVICE CODE: �, PIE: Fee Amount: �� I S 2 Amount a' S� on Payment Date &W Payment Type C% Invoice # Check #3o2,2- Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08