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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property / FACILITY ID # SERVICE REQUEST # uRf4C E s IDENToz- SAN JOAQUIN COUN EXT. 4a zsq, (2-THI P4 r V C4 al S V I- nom7 WNER / OPERATOR HOME Or MA NG ADDRESS CHECK If BILLING ADDRESS Ef MR ,-n X f• f� S u S A N D / 0 F 4 EQA( N C- a STATE t12Azip `r 30 I FACILITY NAME ASSIGNED TO: �OEMPLOYEE SITE ADDRESS 179,;-o DATE: 1 /S a Date Service Completed (if already completed): SERVICE COD, Street Number Direction Street Name Cit Zi! Code HOME Or MAILING ADDRESS (If Different from Site Address) ct 2 — L Payment Date tS Street Number Invoice # Street Name CITY STATE ZIP PHONE #1 EXT. APN #LAND USE APPLICATION # (5/d) '20 -40-0-2 PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR I REQUESTOR / / CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# SAN JOAQUIN COUN EXT. 4a zsq, (2-THI P4 r V C4 al S V I- ENVIRONMENTAL L", d HOME Or MA NG ADDRESS HEALTH DEPARTME FAX # ( ) CITY /' O STATE t12Azip `r 30 I I 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 thislication and that the work to be performed will be done in accordance with all SAN JOAQUIN (on, lCOUNTY Ordinance Codes, Standar , S ATE and F laws. APPLICANT'S SIGNATURE: DATE:Z — PROPERTY / BUSINESS OWNER❑ OPERATO / MANAGER ❑ THER 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 environmenta��t information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t S provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: T� �!) / 15 2071 COMMENTS: SAN JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTME ACCEPTED BY: L EMPLOYEE #: DATE: I f /S r7 ASSIGNED TO: �OEMPLOYEE #: DATE: 1 /S a Date Service Completed (if already completed): SERVICE COD, PIE: a J a Fee Amount: ijjl� Amount Paid ct 2 — L Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 YA T