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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property / . Ci (_— ` / FACILITY ID # BUSINESS NA 7L' SERVICE REQUEST # PHO EX To � J�'2 Z /D (Co.( EMPLOYEE #: HOME Or ILINGADRRESS S ('Uig OWNRATOR FAX# CITY �� /� STA7v�e�L ZIP SL' if already completed): SERVICE CODE: !> Z�? CHECK If BILLING ADDRESS FACILITY NA IE r Ji Fee Amount: us / '00 Amount Paid e S ayment Date 21 �j SIT DDRE§ Z Street o'T Invoice # # 2 % Y `` 5 c / /Z /� ,`Z � Number Direction reet N. . Cit Z17/o�d/ Code HOM Or M ILI ADDR �`�, S If Werent from Sit A dress) C��I t\�� Street Number Street Name CITY tv�_ ST*�,,TE C"el ZIP��-� % G �� PHONE #1 EXT• APN # LAND USE APPLICATION # 126x1 Z 2 — %C� to�( l PHONE #2 ( ) ExT. BOS DISTRICT �71 LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR� /1 I / . Ci (_— ` / CHECK If BILLING ADDRESS BUSINESS NA 7L' PHO EX To � J�'2 Z /D ACCEPTED BY: EMPLOYEE #: HOME Or ILINGADRRESS � C� /✓ FAX# CITY �� /� STA7v�e�L ZIP SL' 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 COUNTY Ordinance Coc APPLICANT'S SIGNATURE: PROPERTY/ BUSINESS OWNER LJ application and Pat the w -be-performed will be done in accordance with all SAN JOAQUIN STATE alld ERAL � l ATE: OPERATOR /MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BlGLlNG PARTY, proof of au thorization 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 Al environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at octime it is provided to me or my representative.CEIVMW �� RE TYPE OF SERVICE REQUESTED: COMMENTS: &C SEP 2 1 2ull SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: 2� ASSIGNED TO: /� ale EMPLOYEE #: f DATE: 2 Date Service Completed if already completed): SERVICE CODE: !> Z�? P 1 E: L/O Fee Amount: us / '00 Amount Paid e S ayment Date 21 �j Payment Type o'T Invoice # # 2 % Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)