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SANJOAQUIN *NTY ENVIRONMENTAL HEAL'I'I-`l'AR'1'MEN'I' SERVICE REQUEST Type of Business or Property TYPE OF SERVICE REQUESTED: FACILITY ID # SERVICE REQUEST # '�vL GO�NTY SAN JOAQp iN SER�I0vSS10N PUB�ME iA�HEA�1H . ENVIRO APPROVED BY:�� t EMPLOYEE #: - DATE: OWN PERATOR EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: C` P / E: CHECK if BILLING DRESS Fee Amount: Amount Paid 1 �� !_ Payment Date Z Y - Payment Type Invoice # Check # �3 e Received FACILITY NAME SITEADDRES� � / Street -Number Direction Street Name Cit ZI CodC HOME or MAILING ADDRESS (It Different from Site Address) Street Number Street Name CITY STATE zip PHONE #1 . EXT. APN # LAND USE APPLICATION a PHONE #2 ( ) EXT. BOS DISTRICT LOCATION CODE (-� CONTRACTOR LARVICE REOUESTOR REQUESTOR �cT CHECK If BILLING ADDRESS B (NESS NAME PHONE# EXT. Z(J:�33 HOME Or MAILING ADDRESS FAX # CCD- IS6 g` cwt) ��/— ?,3qq Cn STAT Fzip / 01 BILLING ACKNOWLEDGEMENT: 1, 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, Standard STATE an 'EDERAL laws. APPLICANT'S SIGNATURC: I h AN -A/1- DATE: I'HOPERTY / BUSINLSS OWNIat ❑ OPLItATOR / MANAGER 10' O'rinot AuTmowzl D AGENT ❑ If APPLICANT is Hot 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 availablc and at the same time it is provided to me or my representative. ASN 't EHD 48-01-025 REVISED 6-5-02 ived By: SERVICE REQUEST FOR TYPE OF SERVICE REQUESTED: COMMENTS: ,�lt11 � '�vL GO�NTY SAN JOAQp iN SER�I0vSS10N PUB�ME iA�HEA�1H . ENVIRO APPROVED BY:�� t EMPLOYEE #: - DATE: ASSIGNED'TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: C` P / E: Fee Amount: Amount Paid 1 �� !_ Payment Date Z Y - Payment Type Invoice # Check # �3 e Received EHD 48-01-025 REVISED 6-5-02 ived By: SERVICE REQUEST FOR