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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # 9-E JUN PHONE# EXT. SAN J 2�2' s m?'00 I-- HOME OP AILING AfpPRESS �} 21101 FAX# ay OWNER / OPERATOR ASSIGNED TO: 1 CITY O/, / Y Q � CHECK If BILLING ADDRESS FACILITY NAME PIE: Fee Amount: 3 SITE ADDRESS oZ 35 AL %✓/N� A y ENve 5 iockTanl gsao� Street Number Direction Street Name Invoice # Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) /ate 9 Street Number Street Name CITY 2 CCS O/� STATE ZIP P�H0N7EE #'1 EXT- APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT r LOCATION DE (.7o -¢ ) 6 -o0 C CONTRACTOR / SERVICE REQUESTOR P I REQUESTOR CHECK If BILLING ADDRESS e//e Dalv SCF/V�r BUSINESS NAME JUN PHONE# EXT. SAN J 2�2' r � HOME OP AILING AfpPRESS �} 21101 FAX# ay DATE: ASSIGNED TO: 1 CITY STATE n ZIP 153b 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 I have prepared thi4appl' and tha e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standard FE aws. APPLICANT'S SIGNATURE: DATE: 4� PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER ADTHORIZED AGENT ]JAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule AtITHORIZATION 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: S Ge K /!i O PD 97-tREVIEW V& COMMENTS: SCF/V�r JUN SAN J 2�2' _ ENVjAQU/N y`�ACT RCNM CC1JN 21101 ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: 1 EMPLOYEE #: S DATE: w Date Service Completed (if already completed): SERVICE CODE: 2� PIE: Fee Amount: 3 Amount Paid Payment Date Payment Type Invoice # Check # 0110 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1712003