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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property t c�-c�t C., CHECK if BILLING ADDRESS 0 FACILITY ID # �nSERVICE REQUEST # �ONq(� OWNER / OPERAT R ��1 J .. S CHECK If BILLING ADDRESS arC' STATE ZIP DATE: FACILITY NAME ASSIGNED TO: S SITE ADDRESS t, 7 ��Ir..I DATE: /� U Date Service Completed (if already completed): SERVICE CODE: 6 1 E: y as Fee Amount: f, Sa Direction Payment Date uV I r • Invoice # HG or MAILING ADDRESS (If Different from Site Address) Receive By: G 0O -i� a it Street Name CIT(TE ZIP PHONE #1 20 -l� ExT• APN # t)871ga° 1 LAND USE APPLICATION # PHONE #2 ( ExT• BIDS DISTRICT a LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR j, C (� V J CHECK if BILLING ADDRESS 0 BUSINESS NAME PN L1 / /�6T 7 b HOME or MAID ADDRESS C �0 ACCEPTED BY: FAx # \ 04 CITY G C4 4, 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 certifv 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 O,L FEDERAL/laws. o 2'/ APPLICANT'S SIGNATURE: (j)n' J 4L4 DATE: / ev -L)�f PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑&f OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 a�rvsessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sam. f provided to me or my representative. rrJ �T 11.4 TYPE OF SERVICE REQUESTED: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) 0 COMMENTS: F -}ref Pe11H14 Avmbv( 163r.(:,SeP)�' 5 'S�7eM is c Y il� l 11e C, rP�, Co( e ' A H�.RON/NCpV A -� N ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: S EMPLOYEE #: DATE: a Y Date Service Completed (if already completed): SERVICE CODE: 6 1 E: y as Fee Amount: f, Sa Amount Pai ae 00 I Payment Date Payment Type CI� Invoice # Check # J Receive By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) 0