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SAN JOAQL uv COUNTY ENVIRONMENTAL HEAL1 x. DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # SERVICE REQUEST # FAX # CITY STATE ZIP ,11 Sjq a 2014 yEA NOR�MN COIN Th SEP FNTq� rY ARrMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED T0: OWNER / OPERATOR EMPLOYEE #: DATE: _ ►. �, CHECK If BILLING ADDRESS FACILITY NAME LA P / E: `) !� Fee Amount: 21 Amount Pai / aS Paymen �- Payment Type SITEADDRESS . ,� S 1� (�fl riff �i41-e Rcl �°�1e ► 2�i Received By: X53 `t'1 Street Number Direction , Street Name Cit Zi Code HOMEr MAILINy�G ADDRESS (If Different from Site Address) ('fiEFAD11"DLE Street Number Street Name CITY L— STATEzip t ^ A 2 PHONE #1 ExT• (x" h � APN # LAND USE APPLICATION # PHONE #2 Ex -r. ( ) BOS DISTRICT 1[ LOCATION CODE 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 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 w r to be performed will be done in accordance with all SAN JOAQUTN COUNTY Ordinance Codes, Standards, STATE and F/�i / 1 s APPLICANT'S SIGNATURE: < 6 ( Z e' t DATE:�� PROPERTY / BUSINESS OWNEROPERATOR/ 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available j the same time it is provided to me or my representative. 1 1 14 Iy j►�/IWw TYPE OF SERVICE REQUESTED: COMMENTS: /� ,11 Sjq a 2014 yEA NOR�MN COIN Th SEP FNTq� rY ARrMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED T0: EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P / E: `) !� Fee Amount: 21 Amount Pai / aS Paymen /, Dae `t �3 / Payment Type Invoice # Check # 1 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003