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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property qWX&Pt A4 L-Ctz c.t �-i' kf5 FACILITY ID # BUSINESS NAME SERVICE REQUEST # PHONE # C4 ExT. 9- -3 EMPLOYEE #: DATE: ';Z0 HOME or MAILING ADDRESS DATE: FAX # OWNER / OPERATOR / CHECK if BILLING ADDRESS ❑ Fee Amount: 3 p Amount 11341304 FACILITY NAME ( ( W Payment Date Z��Z SITE ADDRESS �� 7�(/ Invoice # Check # Receive tL� �- Street Number Direction Street Name Zi Code HOME or MAILING ADDRESS (If Different from Site Address) As/qa� ��//// Street NumberT Street Name CITY STATE ZIP MU PHONE #1 Exr. APN # LAND USE APPLICATION # 02 � fl�QUlly PHONE #2 ExT• ( ) BOS DISTRICT 03 S 17TMEIv Z T,it CONTRACTOR / SERVICE REQUESTOR REQUESTOR qWX&Pt A4 L-Ctz c.t �-i' kf5 CHECK if BILLING ADDRES, BUSINESS NAME �iLL c�l Fcttl��— Gil✓h &Gtl;t 04 71�'�' PHONE # C4 ExT. 9- -3 EMPLOYEE #: DATE: ';Z0 HOME or MAILING ADDRESS DATE: FAX # CITY 1 STATE/ ZIP j j •' ri 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' : �_. DATE: A / PROPERTY / BUSINESS OWNERL�1, OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANTis 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. TYPE OF SERVICE REQUESTED: qWX&Pt A4 L-Ctz c.t �-i' kf5 COMMENTS: /1�Z`CtSa✓� l'ectCtl (1'4-e5 �iLL c�l Fcttl��— Gil✓h &Gtl;t 04 71�'�' ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: I EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: 060 P 1 E: 49-0 Fee Amount: 3 p Amount 11341304 Payment Date Z��Z Payment Type Invoice # Check # Receive tL� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003