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• SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # DATE: CHECK if BILLING ADDRESS BUSINESS NAMErffil�� DATE: Date Service Completed (if already completed): OWNER/ OPERAT R t Fee Amount: Amount Paid I CHECK If BILLING ADDRESS FACILITY NAME l� /1; ki HOME or MAILING ADDRESS Received By: SITE ADDRESS . � f l C Le Street Number Di a ion e' 1 Street Name Cl Cit Code HOME or MAILING ADDRESS (If Brent from Site Address) zip Street Number Street Name CITY STATE zip PHONE #1 EXT, X33 — �3� APN # LAND USE APPLICATION # ( Z��c� ► I PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE „ CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: ACCEPTED BY: (�AC,ffl�A) DATE: CHECK if BILLING ADDRESS BUSINESS NAMErffil�� DATE: Date Service Completed (if already completed): PHONE E.T. Fee Amount: Amount Paid Payment Date Payment Type Invoice # HOME or MAILING ADDRESS Received By: FAX # CITYSTATE 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, Standards, ST and FEDERAL laws. APPLICANT'S SIGNATURE: r DATE: 6finl PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPL/CANT 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: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003