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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # COMMENTS: SERVICE REQUEST # CHECK If BILLING ADDRESS (sr94EC, Kd. t SER - SAN JOAQUIN COUNTY BUSINESS NAME OWNER PERATOR PHONE# EXT. V -RC-- HEALTH DEPARTMENT CHECK If BILLING ADDRESS FACILITY NAME HOME or MAILING ADDRESS CII �At tel). t-0 PCO k- k os:g SITE ADDRESS A;'Wl I 1 S 8 }- t 9 o ` t�umber Directi n Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) P i E: 7i�Cd Fee Amount: 0'I::1 Amount Paid Street Number Payment Date % a S Street Name CITY STATE ZIP PHONE#i Exr. Received Received By: APN # LAND USE APPLICATIO # DT -77 5 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: CHECK If BILLING ADDRESS (sr94EC, Kd. t SER - SAN JOAQUIN COUNTY BUSINESS NAME PHONE# EXT. V -RC-- HEALTH DEPARTMENT (Z-04 8 8 -�- Z G 3 9 HOME or MAILING ADDRESS FAX # ASSIGNED TO: G t-0 PCO k- k os:g EMPLOYEE #: (zo -1 ) S 8 }- t 9 o ` CITY STATE uJ ZIP 9 S Z 3 6 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 to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 1,&knDATE: —?/2 PROPERTY/ BUSINESS OWNER ❑ OPERAT / NIANAGER ❑ 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 availab0'ALh"4me time it is provided to me or my representative. R F CEIV E [) TYPE OF SERVICE REQUESTED: COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: G EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P i E: 7i�Cd Fee Amount: 0'I::1 Amount Paid -$,;L -7 �, C) Payment Date % a S Payment Type Invoice #I Check # 3 Received Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003