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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# C4 OWNER/OPERATOR vCHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS G t r PA /;' Street Number Direction jteet a�,r�e City j ode HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE#1 Ext. APN# LAND USE APPLICATION# PHONE#2 Exa. SOS DISTRICT LOCATION CODE CONTRACTOR/SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESSO "-ww BUSINESS NAME PHONE# Ext. HOME or MAILING ADDRESS FAX# C17Y/--e"A,7-, STATE 455ev 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. I also certify that I have prepared this application and that the work tp be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE.and FEDERAL laws. I APPLICANT'S SIGNATURE: } DATE; / PROPERTY/BUSINESS OwNERp- 'OPERATOR/MANAGER © OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING)PANTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 ENVIRONI%WNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERviCE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEEDATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE; P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003