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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # --J SERVICE REQUEST # PHONE # EXT. IEP 2 g 202, a - HOME or MAILING ADDRESS SAEHV/RONIN COON FAX # D, F3 Loy, HEALTH pE ARTMENT OWNER / OPERATOR CITY RLQ STATE A ZIP . / K R �✓v ,f Q CHECK If BILLING ADDRESS FACILITY NAME ASSIGNED TO: SITE ADDRESS /745-4 DATE: pN So5Tejv 7-/Lgc� ?-5-3 04 Street Number Direction Street Name t Zip Code HOME or MAILING ADDRESS(If Different from Site Address) Payment Date 5Ar l ' ! F— Street Number Street Name CITY STATE ZIP PHONE #1 EXT• ��► APN # 70 LAND USE APPLICATION # eel -s PHONE #2 ExT• BOS DISTRICT s LOCATION COD CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS 19 /� N COMMENTS: BUSINESS NAME PHONE # EXT. IEP 2 g 202, a - HOME or MAILING ADDRESS SAEHV/RONIN COON FAX # D, F3 Loy, HEALTH pE ARTMENT c > CITY RLQ STATE A 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 a0fication and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards ATE and F L laws. APPLICANT'S SIGNATURE: DATE: g Z /A PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IN f 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. OA %e. -- TYPE OF SERVICE REQUESTED: tX P /40 ATS tz)AD II L D D COMMENTS: IEP 2 g 202, SAEHV/RONIN COON HEALTH pE ARTMENT ACCEPTED BY: EMPLOYEE #: DATE: j) ASSIGNED TO: EMPLOYEE M DATE: 1 Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount: ` Amount Pa i l l �Z) Payment Date Payment Type C1"' Invoice # Check # 37 3 Received By' EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003