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J ... ,a. vv.a�va.� vvvi�i l iii 11a\Vi�i�li'J1�1AL 11JL/AL ll\1iI11L1\1 SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS ❑ FACILITY ID # SERVICE REQUEST # BUSINESS NAME SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PHONE# - EMPLOYEE #: OWNER PERATOR HOME Or MAILIN DQRESS/I p i ©� ❑ 1 t C J CHECK if BILLING ADDRESS FACILITY NAME CITY L,4 in d STATE ZIP SERVICE CODE: P I E: SITE ADDRESS 41w4umber 1 J Diu di n Street Name City Zio Code HOME or MAILING ADDRESS (If Different from Site Address) Check # �� Received By: (A Street Number Street Name CITY / y y/y (/i STATE ZIP PHONE#1 EXT. APN # LAND USE APPLICATIO # cry) 32�1'- D7 PHONE #2 ExT ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS ❑ A a, (S'W COMMENTS: BUSINESS NAME SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PHONE# - EMPLOYEE #: HOME Or MAILIN DQRESS/I p i ©� ASSIGNED TO: I (AX#) �� J� oy t C J DATE: CITY L,4 in d 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. 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: DATE: �iT2/Z�J(a PROPERTY/ BUSINESS OWNER ❑ OPERAT / MANAGER ❑ OTHER 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 availab qA Lhp f4me time it is provided to me or my representative, PEC— EiVED TYPE OF SERVICE REQUESTED: COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: I EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid J Payment Date Payment Type "I, - Invoice # Check # �� Received By: EHD 48-02-025 YR FOfIN=,'(�olde"r"Rod} REVISED 11/17/2003