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SAN JOAVN COUNTY ENVIRONMENTAL HEALWEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK 11 BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I Direction e a e Cit ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number trees Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 PJtT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK 11 BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS Fax# <br /> 1 1 <br /> CITY STATE ZIP <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 /> 1 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGEROTHER AUTHORIZED AGENT❑ <br /> (fAPPLICANT is not the BILLING PARTY proof o•f 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 i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (rf already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />