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SAN JOAQUVCOUNTY ENVIRONMENTAL HEALTH NOPARTMENT SERVICE REQUEST Type 01 O�Property FACILITY ID # BUSINESS NAME ' jD r� ICE�� # � �� HOME or MAILING ADDRESS :]— +J ��ER 0' 8 OWNER / OPERATOR STAT ZIP C �/ `�Y W CHECK If BILLING ADDRESS F ILITY NAE �owS pp�� EMPLOYEE #: 6y e ASSIGNED TO: l� i SITE ADDRESS ' f� DATE: Date Service Completed (if already completed): ( I SERVICE CODE: PIE: ql 0� Street NumberDirection Amount Paid I �� Street Name 7 City Zip Code HOME orADDRESS (If Different from Site Address) I Recei ed By: 3L/i? ` i? m L -we Street Number Street Name CIG STATE ZIPLim f PHONE #1 E.T. I �> -7 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR J''� n I �' , ` �,'n CHECK If BILLING ADDRESS Y L BUSINESS NAME ' jD r� ® y ✓ / )' 1 q G 8 PHO NEEXT. # r7 HOME or MAILING ADDRESS :]— +J FAX # ( ) CITY G STAT ZIP C �/ 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, STATE and FEDE AL laws. 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 assessor t information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ® y ✓ / )' 1 q G 8 h'Fq�T�R N �H co4 y�F HT MFNT ACCEPTED BY: "(—) % `t pp�� EMPLOYEE #: DATE: 1+L ASSIGNED TO: l� i EMPLOYEE #: tow Y�z DATE: Date Service Completed (if already completed): ( I SERVICE CODE: PIE: ql 0� Fee Amount: ! ��'j Amount Paid I �� Payment Date 7 Payment Type Invoice # Check # I Recei ed By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08