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SAN JOAQUIN COUNTY ENVIRONIIIENTAi., HEAL'f'tl DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />PAYMENT <br />SERVICE REQUEST # <br />% _f <br />-)D a 5 Y� ( <br />CITY <br />5 e ' 3 � L It <br />1 <br />EMPLOYEE #: HEAL <br />ASSIGNED TO: n <br />EMPLOYEE #: <br />DATE: <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />P/ E: Z 3D <br />& <br />Amount Paid <br />FACILITY NAME <br />r � <br />Payment Date l <br />Payment Type <br />SITE ADDRESS Lj !� 1 e17.) <br />Check # <br />eceived By: <br />T <br />StreetNumber <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />( ) <br />BOS DISTRICT 6)k <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1 Y <br />t+ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PAYMENT <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY <br />STATE-:, �. ZIP rf C-'10� <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:-htrl I \1� DATE: `2" <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1� <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required —� Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environnlental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: he 0acc) (olcoucft- t <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JAN 3 12014 <br />SAN JOAQUIN COUNTY <br />ACCEPTED BY: t� �-�,� t <br />EMPLOYEE #: HEAL <br />ASSIGNED TO: n <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: ] (i <br />P/ E: Z 3D <br />Fee Amount: �� �� <br />Amount Paid <br />Payment Date l <br />Payment Type <br />Invoice # <br />Check # <br />eceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />