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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # HOME or MAILING ADDRESS SERVICE RRE� QQUEST# CITY STATE ZIP l I 39 OWNER / OPER/ TOR rtiy►r o SAS 6 CHECK If BILLING 14 ACCEPTED BY: ADDRESS :s ASSIGNED TO: rev EMPLOYEE #: DATE: FACILITY NAME Date Service Completed (if already completed): SERVICE CODE:D �s SITEADDRESS Fee Amount: 4Z <y J I.,,� Payment Date X' Street Number Direction `='°�f/ ��t r Street Name Invoice # City Received By: Code HOME or MAILING ADDRESS (If Different from Site Address) /S 30.0 )o- A T ti' �/;.— Street Number Street N reet Name CITY STAT ZIP // Ccz 1 f PHONE #1 EXT. APN # AND USE APPLICATION # EXT• BOS DISTRICT �471PHONE`/#2 LOCATION CODE CONTRACTOR /SERVICE REOUESTOR REQUESTOR CHECK if BILLING ADDRESS LJ BUSINESS NAME PHONE# EXT. ( ) HOME or MAILING ADDRESS FAX# 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 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 Al 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.IAQ TYPE OF SERVICE REQUESTED: V UL;r/sly EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 sv COMMENTS: �o / I v `TitJ �CIS�� lG L l 01? �z� �� j�� -�69� rtiy►r o SAS 6 H FN,/ qQU ACCEPTED BY: EMPLOYEE #: DATE:lion ,9 ASSIGNED TO: rev EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE:D �s P / E: Fee Amount: 4Z Amount Paid I-197 Payment Date X' Payment Type Invoice # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003