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t SAN JOAQUIOUNTY ENVIRONMENTAL HEALT EPARTMENT 4 SERVICE REQUEST Type Busines or Property FACILITY ID # BUSINESS NAM SERVICE REQUEST # PHON # EXT. OWNER.IOPERATOR 1 I CHECK If BILLING ADDRESS �^ �,� J SAN JOADUIN FACILITY NAME'��I ENVIRONMENTAL DEPARTMENT SITE ADDRESS CITY PLA &G j%� �t%� �k't O` Ut'*"�'J- DATE: ASSIGNED TO: f✓� Street Number t .i tion '/� "'SuetN Date Service Completed (if already completed): SERVICE CODE:P HOMEOr MAILING ADDRESS (If Different from Site A dr ) Fee Amount: Amount Paid ?v 1 S O r Street Number ! � 6 g Street Name CITY / STATE zip Tk 720 r/ PHONE #'I EXT• APN # LAND USE APPLICATION # yo -f) " 1� —I P NE #2 EXT.BOS DISTRICT LOCATION CODE n CON*ACTOR / SERVICE REQUESTOR REQUESTOR 6C CHECK If BILLING ADDRESS BUSINESS NAM PHON # EXT. HOME or MAILING DD ESS FAX #/ SAN JOADUIN ENVIRONMENTAL DEPARTMENT CITY PLA &G STATE zip EMPLOYEE #: DATE: 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 appjication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar , SJATE and-FEREYAL laws. APPLICANT'S SIGNATURE: L DATE: ? < PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 17 1 &/ 11 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required �Titie 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: S PAY VEei COMMENTS: COUNTY SAN JOADUIN ENVIRONMENTAL DEPARTMENT HEALTH ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: f✓� EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE:P I Fee Amount: Amount Paid ?v 1 S O Payment Date ! � 6 g Payment Type Invoice # Check # '3 (0 2 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003