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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST i ype of Business or Property 1, I OWNER / OPERA FACILITY NAME SITE ADDRESS C Street Number Direction HOME Or MAILING ADDRESS (If Different from Site Address) CITY PHONE #1 PHONE #2 ( ) REQUESTOR EXT EXT. APN # FACILITY ID # SERVICE REQUEST # CHECK if BILLING ADDRESS ❑ Ci CONTRACTOR / SERVICE REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME n" PHONE # EXT. J HOME or MAILING ADDRESS -- FAX # R L 6J7 ( CITY ) . STATE l � 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 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: J .r�.<<, 4�f L, — DATE: 7- ) 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 assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided t0 me Or my representative. TYPE OF SERVICE REQUESTED:L COMMENTS: PAYMFNT b in" ---(Z'x �.cv� RECEIVED - J� ACCEPTED BY: C i V7 ASSIGNED TO: Date Service Completed (if already completed): Fee Amount: -4 Amount Paid Payment Type Invoice # EHD 48-02-025 07/17/08 JUL 0 2 2014 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT EMPLOYEE #: DATE: EMPLOYEE #: DATE: SERVICE CODE: / Payment Date Check # 0 P/E: o� �i ed By: 1,QQlc f -14 SR FORM (Golden Rod) ZIP Code I Number Street Name STATE ZIP LAND USE APPLICATION # BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME n" PHONE # EXT. J HOME or MAILING ADDRESS -- FAX # R L 6J7 ( CITY ) . STATE l � 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 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: J .r�.<<, 4�f L, — DATE: 7- ) 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 assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provided t0 me Or my representative. TYPE OF SERVICE REQUESTED:L COMMENTS: PAYMFNT b in" ---(Z'x �.cv� RECEIVED - J� ACCEPTED BY: C i V7 ASSIGNED TO: Date Service Completed (if already completed): Fee Amount: -4 Amount Paid Payment Type Invoice # EHD 48-02-025 07/17/08 JUL 0 2 2014 SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT EMPLOYEE #: DATE: EMPLOYEE #: DATE: SERVICE CODE: / Payment Date Check # 0 P/E: o� �i ed By: 1,QQlc f -14 SR FORM (Golden Rod)