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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS O BUSINESS NAME FACILITY ID # PHONE# AT. SERVICE REQUEST # FAX # ACCEPTED BY: CITY OWNER / OPERATO DATE: If/91 CHECK If BILLING ADDRESS GJ [ EMPLOYEE #: FACILITY NAME DATE: L, g Date Service Completed (if already completed): $ITE ADDRESW P 1 E: 2� / �'�� pA ` Street Number Direction Street Name / Y� Clt Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Recei ed By: vv v Street Number �/ G� �J i5treet Name CITY STATE ZIP PHONE#t EXT. APN #D 3 LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT --- LOCATION COD CONTR*CTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS O BUSINESS NAME C PHONE# AT. HOME or MAILING ADDRESS FAX # ACCEPTED BY: CITY STATE ZIP ER O R , BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autho acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges assoc or activity will be billed to me or my business as identified on this form. l I also certify that I have prepared t ' Ication and that t C to rformed will be done in accordance with all S N JOAQUIN COUNTY Ordinance Codes, Star ar TATE and FEDERAL law . APPLICANT'S SIGNATURE: DATE: 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 at the same time it is provided to me or my representative. / n TYPE OF SERVICE REQUESTED: C COMMENTS: 7 I /� �1 A� ACCEPTED BY: EMPLOYEE #: DATE: If/91 ASSIGNED TO r r EMPLOYEE #: DATE: L, g Date Service Completed (if already completed): SERVICE CODE: P 1 E: 2� Fee Amount: �'�� Amount PaidZ5 Z2 ` Payment Date V Payment Type / Y� Invoice # Check # �8 �7 Recei ed By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)