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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # FsiP 'EFA/ /A I - HOME Or MAILING ADDRESS y xVov 4r 202?` SANJOAQ(11 �. HEALTH 1) pMENrgL 1)' ' ARrM FAX# ,D / V 3 714( OWNER / OPERATOR -ANNE f. STATE JI ZIP / ASSIGNED TO: CHECK If BILLING ADDRESS R, u LLER/;la 01gea if FACILITY NAME Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount, SITE ADDRESS 7,1, Payment Date Invoice # c,g,:� S --?4 Street Number Direction Street Name it c", Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number �r Street Name � T CITY STATE ZIP„ 0 111-1 PHONE #1 EXT. APN # LAND USE APPLICATION # W� ) z; e0 .4 PHONE #Z EXT. BOS DISTRICT ODE ( ) 57 [LOCATION -! CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME C ES E o A/C PHONE # EXT. HOME Or MAILING ADDRESS y xVov 4r 202?` SANJOAQ(11 �. HEALTH 1) pMENrgL 1)' ' ARrM FAX# ,D / V 3 714( EMPLOYEE #: ) CITY STATE JI ZIP / 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 ap ration and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, TE and F L laws. APPLICANT'S SIGNATURE: DATE: // PROPERTY/ BUSINESS OWNER 13 R / OPERATOMANAGER ❑ 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 RE D: 17 alj &Poz—F- rMe ��I COMMENTS: y xVov 4r 202?` SANJOAQ(11 �. HEALTH 1) pMENrgL 1)' ' ARrM ACCEPTED BY: EMPLOYEE #: DATE: r ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount, Amount Paid ° Payment Date Payment Type Ilk- Invoice # Check #37-// Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003