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SAN JOAI N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME // 1 <br />SAN JOAQUIN <br />ENVInOME COUNTY <br />)SITEADDRESS„/��jQ�/ <br />/ K, Street Numbbr <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different f9m Site Address) <br />FF <br />DATE: <br />ASSIGNED TO: 6 <br />Street Number <br />DATE: <br />Street Name <br />CITY�r TAT <br />ZIP <br />� <br />J <br />PHO #1 / E'�T <br />e <br />APN # <br />LAND USE APPLICATION # <br />7 <br />Payment Type <br />Invoice # <br />Check # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX # <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 tha work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT ,and FEDERAL law <br />APPLICANT'S SIGNATURE. /��-- --- DATE: � <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sie n 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 and at the same time it is <br />provided to me or my representative. / PAVel.-. - <br />TYPE OF SERVICE REQUESTED: <br />F? -” / <br />COMMENTS: <br />FEB 2 J 2013 <br />SAN JOAQUIN <br />ENVInOME COUNTY <br />HEALTH DEpARTMENT <br />ACCEPTED BY: <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: 6 <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 0 <br />P / E: <br />Fee Amount: <br />r <br />Amount PaidOD <br />Payment Date <br />7 <br />Payment Type <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />