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SAN JOAQUIN COUNTY tNVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A CHECK If BILLING ADDRESS <br />C <br />FACILITY ID # <br />NONE # EXT. <br />SERVICE REQUEST # <br />) <br />tc <br />Fax# <br />-? -, <br />OK <br />OWNER i OPERATOR <br />EMPLOYEE #: <br />DATE: <br />Date Service Co pleted (if already completed): <br />SERVICE CODE: U01 <br />CHECK If BILLING ADDRESS <br />P I E: <br />Fee Amount: <br />FACILHY NAME:. <br />Amount P ls6 U� <br />Payment Date 2Z <br />Payment Type <br />t <br />Check # )Sb/+7 <br />SITE ADDRESS <br />?,6r kry <br />I <br />It— S rf eat Number <br />Direction <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PH�ONPE�#i EXT. <br />APN # <br />LAND USE APPLICATION # <br />(/VO,I RK -? Cr E <br />PHONE #2 EXr. <br />BOS DISTRICT <br />LOCATION CODE <br />('&R) ) O J <br />CONTRACTOR / SERVICE REQUESTOR <br />REQDESTDR <br />A CHECK If BILLING ADDRESS <br />C <br />BUSINESS NAME <br />NONE # EXT. <br />( 1, <br />) <br />HOME or MAILING ADDRESS <br />Fax# <br />-? -, <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <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 SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT1:�� <br />F. laws. <br />APPLICANT'S SIGNATURE: � DATE: to 9-( <br />PROPERTY/ BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />fAPPL/CANT isnot the BILLING PARTY proof of authorilation 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 an lta me time it is <br />provided to me or my representative. I A�..II_17ENT <br />TYPE OF SERVICE REQUESTED: Q <br />1 <br />n�j <br />Ep <br />COMMENTS: 8ANJ <br />j, "yIR�UINCOUNTY <br />HF��O PKR7 ' N7 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Co pleted (if already completed): <br />SERVICE CODE: U01 <br />P I E: <br />Fee Amount: <br />Amount P ls6 U� <br />Payment Date 2Z <br />Payment Type <br />Invoice # <br />Check # )Sb/+7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />pr -6649V S <br />