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SAN JOAQUIN `AUNTY ENVIRONMENTAL HEALTH 7'FPARTMENT SERVICE REQUEST Type ausiness or Property FACILITY ID # PH N # SERVICE REQUEST # HOME Or MAILING ADDRESSFAX# ,o6d 3(0� 5I,�o v OWNE OPERATOR�� O �/ L�-per- OO\3No CHECK If BILLING ADDRESS ❑ FACILITY NAME PQV1N TPS SPAN P �TME�T SITE ADDRESS J Street Number pc.J Direction �7/t7 v U/( �4kt ACCEPTED BY: �� HOME or MAILING ADDRESS (If Diffe t from Site Address) EMPLOYEE #: DATE: ., ASSIGNED TO: Street Number ITE: Date Service Completed f ready completed): CITY � � In 11 � STATE ZIP PHONE #1 EXT' Fee Amount: APN # Amount Paid LAND USE APPLICATION # (AN) -Q .3 3 -2-3 OS^ Payment Type J Invoice # Check # S� I PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR / i , x Ill I , CHECK If BILLING ADDRESS BUSINESS NAME PH N # Exr. HOME Or MAILING ADDRESSFAX# (;V,?) l -&3 4-< CITY OO\3No 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 form. I also certify that I have prepared application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standa ,STATE and F ERAL laws. APPLICANT'S SIGNATURE: Q, / WL/ DATE: t% PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN VL , 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 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. —1Al TYPE OF SERVICE REQUESTED: LN COMMENTS: OO\3No PQV1N TPS SPAN P �TME�T N ACCEPTED BY: �� EMPLOYEE #: DATE: ., ASSIGNED TO: EMPLOYEE #: 1 (o+ ITE: Date Service Completed f ready completed): SERVICE CODE: P 1 E: !// d Fee Amount: Amount Paid Payment Date 3 -2-3 OS^ Payment Type J Invoice # Check # S� I Received By: EHD 48-02-025 REVISED 11/17/2003 ?� SR FORM (Golden Rod)