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SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'T'H DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: <br />t <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />ASSIGNED TO: <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />Date Service Completed (if already completed): 777[SERVICE <br />CODE: <br />SITE ADDRESS <br />�C S,re\ettNumber <br />Direction <br />Street Name <br />Payment Date <br />lU Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Received By: <br />Street Name <br />CIN <br />STATE zip <br />' <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT --71 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />j CHECK if BILLING ADDRESS ❑ <br />BUSINESS NAME l PHONE# EXT. <br />L I M (269 <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITYnma STATECP - ZIP rip), TbIn <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 JOAQUrN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: m ( a k- DA'rE:: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 7aJ <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 envirolmlental/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 />S 1 <br />TYPE OF SERVICE REQUESTED: he lace) <br />COMMENTS: <br />t <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): 777[SERVICE <br />CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />