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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Busi ess r Property FACILITY ID # ( MA/14 SERVICE REQUEST # CHECK If BILLING ADDRESS amz 'I - , EMPLOYEE #: �... i BUSINESS NAME OWNER/ OPE TOR ASSIGNED TO: ; U Cr CHECK If BILLING ADDRESS HOME Or MAILING DDRESS� _ /,I I/// i � FACILITY NAME CITY ^ r -1W hAl SERVICE CODE: Q PIE: 23 Fee Amount: '0.2� S LTA SITE ADDRESS tag S p17 Payment Date t) I �if Invoice # Street Number Directio J tr e m Zr Code HOME Or MAILING ADDRESS (If Diff ent from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 XT. 95-1- APN # LAND USE APPLICATION # L53-; PHONE #2 EXT. BOS DISTRICT Z�l( LOCATION CODE t ) C ( j CONTRACTOR / SERVICE REQUESTOR REQUESTOR J - ( MA/14 CHECK If BILLING ADDRESS amz 'I - , EMPLOYEE #: �... i BUSINESS NAME DATE:A ,-7 ASSIGNED TO: ; U Cr PHONE # EXT. HOME Or MAILING DDRESS� _ /,I I/// i � FAX # �) 469 CITY ^ r -1W hAl SERVICE CODE: STATE P 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 a11� ication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN 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 to me or my representative. PAYAMlE="4- TYPE OF SERVICE REQUESTED: 5 7— le --4E —i)2 --o COMMENTS: APR Q E-MVIRO NfiT T ACCEPTED BY: EMPLOYEE #: �... i DATE:A ,-7 ASSIGNED TO: ; U Cr EMPLOYEE #: / 'S DATE: Z U 7 Date Service Completed (if already completed): SERVICE CODE: PIE: 23 Fee Amount: '0.2� S LTA Amount Paid tag S p17 Payment Date t) I Payment Type Invoice # Check # D Received By: tj (s EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003