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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NA G SERVICE REQUEST # PHONE# �j _ XT. � �� �� 7� /Cj� 7 lC,� �Y l I: tl . re, CALL (209 FOR INS 24 -HOU REQUI :;;tI ( LJ O NER/OPERATO EMPLOYEE #: FAX # l CHECK if BILLING ADDRESS FACILITY NAME STATEC ZIP14 S' � SITE ADDRESS L� P 1 E: y� O� , ,, / .S� / g gZ Payment Type Invoice # c Check # 2S 3 �� Street Number Direction Street Name Cit Zi HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name ec CITY STATE Zip AU G 2 PHONE #1 Ex -r. 0AN 0 7) 3 ! `% %U APN # 7' S-C�C�.S LAND USE APPLICATION # S i �' ENv°OAQU/Nc PHONE #2 ExT• BOS DISTRICT LOCAT SART ( ) G• CONTRACTOR / SERVICE REQUESTOR REQUESTOR ) e� : s � _ CHECK If BILLING ADDRESS '0 BUSINESS NA G PHONE# �j _ XT. � �� �� 7� /Cj� 7 lC,� �Y l I: tl . re, CALL (209 FOR INS 24 -HOU REQUI :;;tI ( LJ HOME or MAILING ADDRESS EMPLOYEE #: FAX # 20Z EMPLOYEE M DATE: Q7I STATEC ZIP14 S' � NT Ep 021 NTy L ENT 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 erform d Il e done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stm TE and FED Q APPLICANT'S SIGNATU E: .�_. 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: COMMENTS: �✓ / �� I ( } S U n f `'f' �q per , �� 7� /Cj� 7 lC,� �Y l I: tl . re, CALL (209 FOR INS 24 -HOU REQUI ACCEPTED BY: �JZ�� f� _ EMPLOYEE #: DATE: �{/ s'X ASSIGNED TO: EMPLOYEE M DATE: Q7I Date Service Completed (if already completed): SERVICE CODE: U / P 1 E: y� O� Fee Amount: l,� Amount Paid . � Payment Date gZ Payment Type Invoice # Check # 2S 3 �� Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 )953-7697 PECTION. R NOTICE RED.