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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Props FACILITY ID # PHONE # EXT. SERVICE REQUEST # �A CITY STZIP 'Oft SR0018(00Q(05 OW ER OPERATOR CHECK If BILLING ADDRESS FACILITY NAME x SITE ADDRESS ACCEPTED BY: EMPLOYEE 4�3 DATE: r 2--2— LASSIGNED 2SS l V DATE: t 01 )_2 Date Service Completed (if already ompleted): Street Number Direction Serest Name Fee Amount: CI Zip Code HOME or MAILINcG'AODREBLS (If Different from Site Address) , Payment Type Invoice # <--1 ( S J�GI� Sgt- Street Number Check # Street Name CITY STATE ZIP LOd ( V PHONE#t EXT. APN # LAND USE APPLICATION # (2oT) 331 0)—(6 PHONE#iExr. BOS DISTRICT LOCATION CODE (5-Z3) 9 4 6 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK It BILLING ADDRESS Y BUSINESS NAME ! I cIrIll PHONE # EXT. HOME Or MAILING ADDRESS FAx# ( ) CITY STZIP 'Oft 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, T A`TE and FEDERAL laws. APPLICANT'S SiGNATURFj!� 1 I 89 . DATE: PROPERTY / BUSINESS OWNER( OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT iS not the Bl1,LING 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 atm the same time it is provided to me or my representative. A TYPE OF SERVICE REQUESTED: 1v r FC COMMENTS: JAN SMdOA ENVIRQIJ/N OO HF TH OOF' UL ry ACCEPTED BY: EMPLOYEE 4�3 DATE: r 2--2— LASSIGNED ASSIGNEDTO: h �^ EMPLOYEE #: Qr ZS DATE: t 01 )_2 Date Service Completed (if already ompleted): SERVICE CODE: /E: U2, Fee Amount: Amount Pal /S Payment Date , Payment Type Invoice # Check # Receiv d By: EHD 48-02-025 REVISED 11/17/2003 � C, p SLI S52 30 SR FORM (Golden Rod)