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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME CO <br /> SITE ADDRESS 2 o� �!♦ �Tur 0�� w J. � y� / ZQS <br /> Street Number Direction Street Na Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 1r /Id o� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 00 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I) �i <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 <br /> or 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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environmental/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: 1 \ <br /> COMMENTS: r ` 11"C'p Ap 4 l oyl (Lf 210, <br /> ACCEPTED BY: EMPLOYEE#: 000 DATE: 6 16 Za(6 <br /> ASSIGNED TO: M�� EMPLOYEE#: $00 6 DATE: !'bol <br /> Date Service Completed (if already completed): b ,?,o/ SERVICE CODE: O Q PIE: 9?4 Q <br /> Fee Amount: Amount Paid 10 <br /> Payment Date <br /> Payment Type Invoice# it Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ID <br />