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SAN JOAQLWOUNTY ENVIRONMENTAL HEALTOEPARTMENT SERVICE REQUEST Type of Business or Property EI�i FACILITY ID # CHECK If BILLING ADDRES, SERVICE REQUEST # ACCEPTED BY: ,� / , v 71 o BUSINESS NAME 600 OWNER /OPERATOR 1 i _ CHECK If BILLING ADDRES3R I`� \�t I � ( . SERVICE CODE: i FACILITY NAME HOME or MAILING ADDRESS SITE ADDRESS 0 I �C }C lel• street __ L .�e StNumber Direction Name CITY Cit Zip Code ZIP 6� , HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Ex -r, APN # LAND USE APPLICATION # (wl) ) Y4. 37i PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR EI�i COMMENTS: CHECK If BILLING ADDRES, ��+Mcc R 1� CE: i ylIED SEP 16 20113 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: ,� / , v EMPLOYEE M ?f / � v/ BUSINESS NAME In PHONE# / EXT. Date Service Complete (if already completed): SERVICE CODE: i P / E: Zap g HOME or MAILING ADDRESS Amount Paid O Fax # __ L .�e Check #_ 1 ) - I c} CITY STATE (' ZIP 6� , 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, ATE an EDE L laws. r APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the MLLINGPARTY, 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. TYPE OF SERVICE REQUESTED: EI�i COMMENTS: ��+Mcc R 1� CE: i ylIED SEP 16 20113 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: ,� / , v EMPLOYEE M ?f / � v/ DATE: 7116113 ASSIGNED TO: EMPLOYEE #: (� 2 r DATE: Date Service Complete (if already completed): SERVICE CODE: i P / E: Zap g Fee Amount: 7 S Amount Paid O Payment Date 9l(0 sj Payment Type Invoice # Check #_ Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003