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SAN JOAQICOUNTY ENVIRONMENTAL HEALTII)EPARTMENT SERVICE REQUEST Type of Business or Property 1 7, CHECK If BILLING ADDRESS BUSINESS NAME FACILITY ID # PHONE# EXT. SERVICE REQUEST # COMMENTS: FAX # CITY STATE ZIP IZGOO Z 3 ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: OWNER / OPERATOR EMPLOYEE #: DATE: 2�0, / — I� EMPLOYEE #: DATE: �^ r� C CHECK If BILLING ADDRES Date Service Completed (if already completed): SERVICE CODE: FACILITY NAME P / E: ?J t Fee Amount: 12 Amount Paid"®O Payment Date 4P12-0 l3 Payment Type. Invoice # SITE ADDRESS ! � S `Street Received By: 0 Number Direction treet Name Cit 2i Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR V (, 1 7, CHECK If BILLING ADDRESS BUSINESS NAME •. PHONE# EXT. HOME Or MAILING ADDRESS COMMENTS: FAX # CITY STATE ZIP 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, STA an E RAL law APPLICANT'S SIGNATURE: DATE: o 3 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER M OTHER AUTHORIZED AGENT ❑ 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. PAYME1uT TYPE OF SERVICE REQUESTED: (� �j`-- RECEIVED •. i� COMMENTS: III 2 i, JUN ® 2013 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: 2�0, / ASSIGNED TO: EMPLOYEE #: DATE: �^ r� C Date Service Completed (if already completed): SERVICE CODE: P / E: ?J t Fee Amount: 12 Amount Paid"®O Payment Date 4P12-0 l3 Payment Type. Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003