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SAN JOAQUVWUNTY ENVIRONMENTAL HEALTH 10ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK if BILLING ADDRESS FACILITY NAME l ML�kkkk ��`! SITE ADDRESS k 1 �<V � W� �i Code :S.tr.:eet:Num:berJDI ec to et ame HOME or MAILING ADDRESS (If Di rent from Site Address) StreetNumber Street Name STATE ZIP CITY Exr. APN# LAND USE APPLICATION# PHONE#'I ( ) ,:j'a- O ExT. BOS DISTRICT LOCATION CODE PHONE#2 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR \\l \ CHECK If BILLING ADDRESS v PHONE# E� BUSINESS NAME _ Ilkw C, FAX# HOME or MAILING ADDRESS STATE CITY �`G BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvIRONMENTA.L 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 and FEDERAL laws. APPLICANT'S SIGNATURE: \ � � �V` _ DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 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 environmentaUsite 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. VTYPEERVICE REQUESTED: EMPLOYEE#: DATE: ACCEPTED BY: EMPLOYEE#'. DATE: ASSIGNED TO: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: SR FORM(Golden Rod) EHD 48-02-025 REVISED 11/17/2003