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Al SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS SERVICE REIIQ�UEST # CITY STATE ZIP n ENVIRON IN `OWNER/ OPERATOR j / % V1��, S �� YI �% `j G✓I � A CHECK If BILLING ADDRESS ❑ FACILITY NAME 4 ✓/ %Cert G 7 e4 ` SITE ADDRESS 2--3.3,L; %� ACCEPTED BY: L.L v Zi Street Nuu mber Number Direction Street Name DATE: C�` Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) P 1 E: Fee Amount: (t)2 Street Number /S� Street Name CITY �%/JQ� Payment Type �I STATE ZIP PH9NE#1 ExT. APN # LAND USE APPLICATION # kC PHONE #2 ExT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS ❑ BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS FAX # CITY 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 certify 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 FEDERAL laws. APPLICANT'S SIGNATURE: �- 6 _,(;� DATE: /Z k /Z, 0 ` e 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 ati�same time it is provided to me or my representative. pA_YMeNT TYPE OF SERVICE REQUESTED:( —�1 .� 1® COMMENTS: 41-N C L I 8 y� SAN ENVIRON IN H CO'J EALTH 0,ePU ZAL ACCEPTED BY: EMPLOYEE #: � DATE: C ASSIGNED TO: --_ EMPLOYEE #: DATE: Date Service Completed (if already Completed: SERVICE CODE: P 1 E: Fee Amount: (t)2 Amount Pai' /S� Payment Dante 7 � r �%/JQ� Payment Type �I Invoice # Check # 13 O Q Z Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)