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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property i� � rr )) J % J FACILITY ID # PHONE # ExT. SERVICE REQUEST # (20�) 2 o 331 HOME or MAILING ADDRESS FAX # CITY STATE ZIP DATE: z j -Z_ OWNER / OPERATOR If BILLING ADDRESS ❑ LU 1 CHECK FACILITY NAME J -� SERVICE CODE: P / E: �Z Fee Amount: $ITE ADDRESS � � r� h � G Payment Type Invoice # —f rJ0 Street Number Direction Street NameTv Cit Zip Codel HOME If.D,ifferentfromSiteAddress) oorQMAILING ADDRESS (1" 0 � 1 (T o `- 0 v ✓a Street Number Street Name CITY Is+b L� C�l IE- STATE ZIP PHONE #1 Exr. ( �) 2-3o i APN # o9g02 0Z LAND USE APPLICATION # PHONE #2 E) r. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR1 AL I CHECK If BILLING ADDRESS i� � rr )) J % J BUSINESS NAME PHONE # ExT. (20�) 2 o 331 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: '2- 2, PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ 5 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 availab ie time it is provided to me or my representative. rATMt TYPE OF SERVICE REQUESTED: lJl FEBCOMMENTS: B 2 5 20 SAN J1 AQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: V V DATE: z j -Z_ ASSIGNED TO: ^ 1� (i� EMPLOYEE #:� DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: �Z Fee Amount: / v Amount Paid lJ � Payment Date Payment Type Invoice # Check # L �O Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003