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SAN JOAQUL .AUNTY ENVH{ONMENTAL HEALTH _ APARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST# CHECK if BILLING ADDRESS BUSINESS NAMEd SQWSS11 .COW OWNER/ OPERATOR l CHECK If BILLING ADDRESS FACILITY NAME FAX om 2 m SITEADDRESS CITY I�. STATEZIP q53 EMPLOYEE#: Street Number Direction Street Nam ASSIGNED TO: CIt City ZI Code HOME Or MAILING ADDRESS (I Different from Site Address) DATE: Date Service Completed (if already completed): / SERVICE CODE: P / E: Street Number Fee Amount: Street Name CITY— -1/ ZIP t PHONE#1 ' EXT, APN# LAND USE APPLICATION It ) 2is PHONE#2 Ezr• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR n(AAP'JEFc CHECK if BILLING ADDRESS BUSINESS NAMEd PHONE EXT. ZkASA4couill • � HOMEO M NG ADD SS I ' FAX / i m CITY I�. STATEZIP q53 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, TATE%%%%��'¢'',d FEDERAL laws. APPLICANT'S SIGNATURE: 'V-Z� DATE:. -- PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ YAPPLLCANT 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. I PA ye TYPE OF SERVICE REQUESTED: n(AAP'JEFc lVr COMMENTS: ZkASA4couill Garr QS AY- . in C YMIGt �� m PART 1fF T ACCEPTED BY: EMPLOYEE#: DATE: Z ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: Q Amount Paid�[ Payment Date Z �Z/ Payment Typee Invoice # Check # / $2 Recei ed By: EHD 48-02-025 �I SR FORM (Golden Rod) � REVISED 11/17/2003