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SAN JOAQUII`` AUNTY ENVIRONMENTAL HEALTF — EPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # MAS 'ZQQ't SERVICE REQUEST # PHONE# ExT' ENNJ►RONMENTA� 1 DEPAIRTMENT H�UTI OWNER/ OPERATOR FAx # q CHECK If BILLING ADDRESS }—� ASSIGNED TO: CITY STATE 0 C, FACILITY NAME yYi rvl S �� c SERVICE CODE: SITE ADDRESS 7-J L� S �� i 5 �• , �;C Payment Date t C K t-0 11 -5 O C� U� Street Number Direction Received By: Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY 1 STATE Cc\ ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (loci) `I b b b 1b 3 --�) PH NE # EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR l CHECK if BILLING ADDRESS COMMENTS: MAS 'ZQQ't BUSINESS NAME — PHONE# ExT' ENNJ►RONMENTA� 1 DEPAIRTMENT H�UTI H ME Or MAILING ADDRESS FAx # q EMPLOYEE#:TLa DATE4 : ✓ U V ASSIGNED TO: CITY STATE 0 C, ZIP �' ` C.) ` \ LSC BILLING ACKNOWLEDGEMENT: 1, 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, Standar , STATE and FEDERAL laws. APPLICANT'S SIGNATURE:_ �,�-- DATE: - o PROPERTY/ BUSINESS OWNER ❑PERATOR / MANAGER El OTHER AUTHORIZED AGENTP If APPLICANT is n re 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. . N A'.--T\11- TYPE OF SERVICE REQUESTED: COMMENTS: MAS 'ZQQ't SAN JOAQOIN COUNT ENNJ►RONMENTA� 1 DEPAIRTMENT H�UTI ACCEPTED BY: EMPLOYEE#:TLa DATE4 : ✓ U V ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: 7 C f-lv—\ Amount Paid ]$�7 I C70 Payment Date Payment Type ,/ Invoice # Check # q l�L Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003