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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE # EXT. SERVICE# FAX # ( ) CITY STATE LP �REQUEST Q W Li "l OWNER OPERATOR H�cyOlvuilv Oil D��MNT CHECK If BILLING ADDRESS FACILITY NAME O U s O ACCEPTED BY: w ,�S f.. Fj SHE ADDRESS EMPLOYEE ASSIGNED TO: L LOGKe�'Ot^a ysZ3� L Street Number Direction (� Street Name SERVICE CODE: Cit 21 Code HOME r IVIAILING ADDRESS (If Different from Site Address Payment Date Q EC Street Number # Street Name CrrY STATE ZIP PHO,NEE#1 ExT. APN # LAND USE APPLICATION # Q,p ) PHONE#2 ExT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS FAX # ( ) CITY STATE LP 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 S. *�� APPLICANT'S SIGNATURE: DATE: C5 '_U/O ^Z ` PROPERTY/ BUSINESs OWNER❑ OPERATOR/MANAGER ❑ 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 available and a same time it is provided to me or my representative. h� ��r, TYPE OF SERVICE REQUESTED: w 0 ' J a YX� ��/ COMMENTS: 2 6 'lo ENJOgQUIpO < 1% H�cyOlvuilv Oil D��MNT ACCEPTED BY: w ,�S f.. Fj EMPLOYEE DATE: �9 —2, ASSIGNED TO: L EMPLOYEE DATE: �o Z Date Service Completed (if already completed): SERVICE CODE: PIE.. I Fee Amount: Amount Paid Payment Date Q Payment TypeInvoice # Check # 'z.2 Received By: EHD 48-02-025 REVISED 11/17/2003 � [5D,- SR FORM (Golden Rod)