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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP ACCEPTED BY: EMPLOYEE M Z%) z DATE: 2 Q l7 Z t ASSIGNED TO: OWNER / OPERATOR It DATE. rI✓ 00 f -3 Date Service Completed (if already competed): CHECK BILLING ADDRESS� FACILITY NAME P r r Fee Amount: Amount Paid SITE ADDRESS Payment Date I��j. �'r�i� Vh'� L Payment Type �-+r r-_ L Check # Received By: .;L-1 O , Street Number Direction r Street Name city zip Cade HOME or MAILING ADDRESS ((if Different from Site Address) Street Number Street Name CITY STATE ZIP Z ` PHONE#1T�! Ems. APN# LAND USE APPLICATION# (2v� l iso — O g/� �7 - r7 !J it - (] r i PHONE#2 Ex . `-J —z (0 & Ll BOS DISTRICT LOCATION CODE ti0 ) u AG CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# HOME Or MAILING ADDRESS FAx # CITY STATE 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 forth. 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, Sfmtd T TE and FEDERAL laws. ^ ) `J APPLICANT'S SIGNATUR DATE: 0/v PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ IfAPPLICANT is not the BILLING PA21y proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ILi�jP.rwtime it is provided to me or my representative. PA RIB IV t TYPE OF SERVICE REQUESTED: COMMENTS: a A�s2 ,may \ ti pA, l MAR 10 _ENVIRONMENTAL I1TM DEPARTMENT ACCEPTED BY: EMPLOYEE M Z%) z DATE: 2 Q l7 Z t ASSIGNED TO: 6r EMPLOYEE #: �5 DATE. rI✓ 00 f -3 Date Service Completed (if already competed): SERVICE CODE: 5-23 11 P r r Fee Amount: Amount Paid Payment Date 31 (k) a 2, Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003