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y <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property �� <br />FACILITY ID # <br />PHONE# EXT. <br />( ) <br />SERVICE REQUEST# 1 <br />u <br />OWNER / OPERATOR <br />✓iW <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE <br />SITE ADDRESSZGt <br />0 <br />Street Number <br />Direction <br />1 Street Name <br />L�� <br />Cit <br />�S <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SERVICE CODE: <br />Street Name <br />CITY � <br />STATE ZIP <br />S <br />P o <br />� <br />EXT <br />- �� (-(-t (Q2 <br />APN # <br />/7-9 � <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR 11 <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />( ) <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />N <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agrAT Me <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wi ! <br />MD <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all VN 30�Q It "� <br />CONTY Ordinance Codes, Standards, STATE and F DE SAN JOAQUIN COUNTY <br />7/ <br />l lZ —�EN VIRONNIENTAL <br />�P'PLICANT'S SIGNATURE: DATE: <br />KEALTH DEPARTMENT <br />PROPERTY/ BUSINESS OWNER❑ OPE ATOR NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL, HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. J / / , , i /; ., ^ r� <br />TYPE OF SERVICE REQUESTED: <br />r <br />COMMENTS: <br />�A yt C) <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO rG-TY\ C <br />EMPLOYEE #: <br />DATE: 1 �7 <br />Date Service Completed (if alread completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date `5 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />