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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT,,,' i L E J e I.. SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS Street Number I Direction Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#t ExT APN# LAND USE APPLICATION# ( ) PHONE#2 EXT SOS DISTRICT LOCATION CODE I ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# ExT• 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 ENVfRONMENTAL 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY I BUSINESS OWNER 11 OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT IS not the BILLING PARTY proof of authorization to Sight 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 a5 soon a5 It is available and at the Same time It IS provided to me Or my representative. TYPE OF SERVICE REQUESTED: - COMMENTS: ACCEPTED BY: EMPLOYEE#; DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08