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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DE' ARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # TTSERVICE O HOME or MAILING ADDRESS REQUEST # 5/7�®�/ OWNERQ,,y ► �//COPE TO (red O . Na CHECK if BILLING ADDRESS C� F M 1 1 G ASSIGNED TO: S)T� 4RESSS �-� Street Number Direction Date Service Completed (if already Completed): pa G(-Fi t1159,0-7 Street Name Cit Zi Code HOME 0( MAILING ADD$) ��Djfe�nt fro,{n Sit�ddress) (� Street Number Amount Paid Street Name CI}Y Payment Type STATFn ^ ZIP -75�,2 0 7 PHONE #1 E.T. ViA) �� O Received By:i/�, APN # LAND USE APPLICATION # PHONE#2 ( v� /EXT. q- ) '�(�� L"�`/ 7 / t/ i BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX# CITY STATE ZIP 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stan ds, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: ��/- tom— DATE: 1- 1-7– do 1� 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 the or my representative. I I PAYMENT TYPE OF SERVICE REQUESTED: 's—T— ccy� v l RECEIVED COMMENTS: U JAN 17 2012 SAN JOAQUPN Co(JNTy ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: r7 C� ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P I E: n Fee Amount: o -a Amount Paid Payment Date I Payment Type Invoice # Check # Received By:i/�, EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003