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SAN JOAQUIl' ' UNTY ENVIRONMENTAL HEALTVfPARTMENT SERVICE REQUEST Typ f Business or Property �Wolv" CHECK If BILLING ADDRESS BUSINESS NAME i :t FACILITY ID # 3 SERVICE REQUEST # fl0 q OWN / OPERATOR WL CITY CHECK If BILLING ADDRESS ❑ FACILITY NAME ENVIRONMENTAL H -W/ALTVi DEPARTMENT SITEIla DRESS IStreet Number �Q) Dir�lStion � C (%'�`�/,/� t��/��D Zi Code' HOME or MAILING ADDRESS (If Different from Site Addres Street Number Street Name CITY DATE: STATE ZIP PHONE #1 EXT. P 1 E: APN # Fee Amount: 10 LAND USE APPLICATION # PHONE#Z ( ) EXT. Payment Type Invoice # BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME i I PHONE# Err' (' i 1 HOME or MAILING ADDRESS FAX#yRt 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, StandardA STA and FEDERAL laws. `� 1 L/Cf APPLICANT'S SIGNATURE: ( DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ 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. TYPE OF SERVICE REQUESTED: V ,-- �� ECEIV ED COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL H -W/ALTVi DEPARTMENT ACCEPTED BY: EMPLOYEE #: �J DATE: b / ASSIGNED TO:fla. EMPLOYEE #: ZrLqq DATE: Date Service Completed (if already completed): SERVICE CODE: i P 1 E: 2�©� Fee Amount: 10 Amount Paid�0-Cj Payment Date L Payment Type Invoice # Check # -711,o Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)