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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMED SERVICE REQUEST f Type of Business or Property FACILITY ID # SERI BUSINESS NAME SF PHONE # EXT. OWNER I OPERATOR yTFQhOp�+IT E Cr I Cir .T>�t HOME or MAILING ADDRESS l 7 , CHE( FACILITY NAME # SITE ADDRESS EMPLOYEE : � ( / Street Number DI ectIo Street Name ca HOME or MAILING ADDRESS (If Different from Site Address) L�✓ 1 Amount Paid` J Sheet Number Payment Date Street Name CITYTrlac Invoice # STATE 7rll CA PHONE #1 ET, APN # / 1 L) LAND USE APPLICATION # PHONE#2 ExT• BOS DISTRICT CONTRACTOR /SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME SF PHONE # EXT. yTFQhOp�+IT E HOME or MAILING ADDRESS l 7 , C /)FAX 1L IL lJ` `�-�/tom f i. # CITY T�/jL EMPLOYEE : � STATE zip G�- BILLING ACKNOWI!EDGEMENT: 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 JOAQUIih COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. // �/�%1 r — v� G-�"" �.. DATE?tel /G t/I 5 APPLICANT'S SIGNATURE: �� : ,,(( A PROPERTY /BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTp A-\SLa,Lct'JJt- IfAPPLICANT 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 elTvironmental/site asseM4fi information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tiprovided to me or my representative. TYPE OF SERVICE REQUESTED: n� I,n�`'� COMMENTS: i 01 VO `" \ V1Gc,c, 1 c- S (} TY, '� -1 SF yTFQhOp�+IT E N Rr ACCEPTED BY: EMPLOYEE : � DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: v P I E: a o Fee Amount: (�2 Amount Paid` J Payment Date Payment Type `t- _ Invoice # Check # Recelved B EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)