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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS REQUEST # Portable Restrooms PHONE# ExT. Is V Q � g5 �&1�) OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ Rick Van Unen H9&4or MAILING ADDRESS FACILITY NAME FAX # SITE ADDRESS 14250 I Jack Tone Rd I ( ) Manteca 95336 Street Number Direction Street Name Fee Amount: a city Zin Code HOME or MAILING ADDRESS (If Different from Site Address) S(1'6/2 PO Box 839 Street Number Invoice # Street Name CR(pon SATE ZIP l.a 95366 PHONE #1 ExT• (209-423-611 0 APN # j LAND USE APPLICATION # —07 1 0O PHONE #2 ExT• BOS DISTRICT LOCATION CODE ( ) C CONTRACTOR / SERVICE REQUESTOR REQU �� VAS_/ � v T fist �(' LOr.4 cif f) - ud CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: PHONE# ExT. ACCEPTED BY: ,7, L)�� H9&4or MAILING ADDRESS FAX # v 1 DATE: ( ) Date Service Completed (if already completed): CITY 1nU� STATE e ZIP J 5-3 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 a d that e work to be performed will be done in accordance with all SAN �►JOAQUIN COUNTY Ordinance Codes, Standards, �TEd EDE laws. PAYMENT APPLICANT'S SIGNATURE: DATE: RECEIVE© PROPERTY/ BUSINESS OWNER® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ p I I j` O 2822 If APPLICANT is 1701 the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr R IfIQ0 MTY above site address, hereby authorize the release of any and all results, geotechnical data and/or environm sPA information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tl e Itis T provided to me or my representative. TYPE OF SERVICE REQUESTED: SJ / I SU ' AGI � i I I r C h c/ � v T fist �(' LOr.4 cif f) - ud v i COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 3 P / E: 0 Fee Amount: a Amount Paid Z —" Payment Date S(1'6/2 Payment Type Invoice # Check # Received By: /21 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003