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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEPARTMENT SERVICE REQUEST Type of Business or Property Qvb(r� P CHECK IT BILLING ADDRESS FACILITY ID If SERVICE REQUEST # PHONE# 3 ExT. 3 zZcq Z HOME or MAILING ADDRESS qO2 y— Sfeoa�a�79 OWNER I OPERATOR STATE C,q- ZIP CHECK it BILLING ACCEPTED BY: EMPLOYEE #: & ADDRESS FACILITY NAME ASSIGNED TO: � EMPLOYEE #: l.4Zi 3 SITE ADDRESS DATE: lei T I l 0P I _ (I • t� Street Number Direction Street Na a Invoice# CI[ Li Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ExT APN# LAND USE APPLICATION# PHONE#2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ��\J /I w CHECK IT BILLING ADDRESS BUSINESS NAMEr I• COMMENTS:, PHONE# 3 ExT. 3 zZcq Z HOME or MAILING ADDRESS �` _ y— FAX# I 1 1 '5 3 �f - *- CITY o t STATE C,q- 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �z2(�f L��_ DATE: S / PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT❑ IJAPPLICANT is not the BILLING PAR TT 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 t0 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 SEPI CE REQUESTED: V6-6 tN� COMMENTS:, 1U'011 ACCEPTED BY: EMPLOYEE #: & DATE: 5 f Q ASSIGNED TO: � EMPLOYEE #: l.4Zi 3 DATE: Date Service Completed (If already completed): SERVICE CODE: 0P PIE: Fee Amount: 12.Lo C Amount Paid Payment Date Payment Type ✓ Invoice# Check# 3-7:1l Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003