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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �} FACILITY ID # SERVICE REQUEST # 17(1 � V T_V0 PHONE# Exr. ,///,{/19,7 �� CQ OWNER I OPERATOR CHECK if BILLING ADDRESS D FAX # C ryYDE,o�NT CAIS}' FACILITY NAME! m a 1 a CITY STATE ZI P ACCEPTED BY: H� PT v) un .j 111 111 `� �SIITEE ADDRESSF Z Street Number Dlrectlon �Szreername .V Cf Zi Code HOME or MAfLING ADDRE S (If Different from Site Address) DATE: .r �'� Street Number SERVICE CODE: CITY STATE A QIP Fee Amount: I% (J� PHONE #1 ExT• APN # Payment Date `l LAND USE APPLICATION # Invoice # Check # ' � Received By: PHONE #2 EXT. BOS DISTRICT LOCATION CODE 11 (51D)S�S ID'_? CONTRACTOR 1 SERVIG-EREQUESTOR REQUESTOReee�e��—�� CHECK 9f BILLING ADDRESS BUSINESS NAME �~ 1 PHONE# Exr. ,///,{/19,7 �� CQ HOME or MAILING ADDRE FAX # C ryYDE,o�NT CAIS}' (2cl4th2 I .S CITY STATE ZI P 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. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE an EDERAL laws. APPLICANT'S SIGNATURE: DATE: Z '0 l PROPERTY 1 BUSINESS OWNER © OP / 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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me Or my representative. a pd I -- TYPE OF SERVICE REQUESTED: '_? - eic COMMENTS:n S to t I�f% ,///,{/19,7 �� CQ 2��J %�RDq�� C ryYDE,o�NT CAIS}' ACCEPTED BY: H� PT v) un .j 111 111 `� EMPLOYEE #: DATE: 1 ASSIGNED TO: fl 1r it EMPLOYEE M DATE: Date Service Complete (if already completed): .I SERVICE CODE: PIE: Fee Amount: I% (J� Amount Paid Payment Date `l Payment TypeV ;��. Invoice # Check # ' � Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08