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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Lr eARTMENT SERVICE REQUEST Type of Business or Property ACILITY IDD # r15:6 3(ply A SERVICE REQUEST # c3C� � OWNER/ OPERATOR . 1-_ fp ��11/ sys �L7 CHECK if BILLING ADDRES FACILITY NAME / V �(d t, o ``/� r -ST Q f -r EMPLOYEE #: SITE ADDRESS /� l Street Number Direction 6LL A QQ j5 '— Q, IA INI`LZ Street Name �/- � jG City �1 Q 9��1 l Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE CJ7 STATE Zip PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 ( 1 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRES. A J U L 22004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BUSINESS NAME �oI'1� PHONE EXT. ah(?pS EMPLOYEE #: 3/` HOME or MAILING ADDRESS W FAX # z / Fee Amount: I&?) y' CITY /'e't-e S STATE CJ7 ZIP Seo 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 an FEDERAL laws. APPLICANT'S SIGNATURE: DATE: ! 30 -O'`% PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT P'tAott (5 -co, G YlY 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 t0 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. PAYMENT TYPE OF SERVICE REQUESTED: COMMENTS: J U L 22004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APPROVED BY: EMPLOYEE #: DATE: ASSIGNED TO: rLe EMPLOYEE #: DATE: Date Service Completed` (if already completed): SERVICE CODE:121 P / E: Fee Amount: Amount Paid y' Payment Date Payment Type Invoice # Check # 9 Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 J�Qi