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SAN JOAQUIN(tUNTY ENVIRONMENTAL HEALTPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS BUSINESS NAME FACILITY ID # REQUEST # ROL P EC At HOME or MAILING ADDRESS ?SERVICE CITY OWNER/ OPERATOR ` SAN JOAQUkN GOUN "y ❑ H�ONMEgTAL -rtRTMEN1 CHECK If BILLING ADDRESS FACILITY NAME EMPLOYEE #: DATE: ASSIGNED TO: SITE ADDRESS 1q1'5�� r m o nt Date Service Completed (if already completed): Wd SERVICE CODE: Street Number Direction Street Name Amount Paid C' 2i Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Type Invoice # Street Number Street Name CITY STATE ZIP Ck �j j t PHONE #'I ( ) EXT. APN # LAND USE APPLICATION # PHONE #2 ( ) EXT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: P4 I w EXT, HOME or MAILING ADDRESS FAX # (i% -ira�-1342 CITY STATE ZIP i 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: hYM (x\ yk, DATE: , 2Q 12 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT)p If APPLICANT is not the BiLLLVG 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. TYPE OF SERVICE REQUESTED: PAYMENT gn COMMENTS: �JUN�72012 ` SAN JOAQUkN GOUN "y H�ONMEgTAL -rtRTMEN1 ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 9r, PIE: Z [FeeAmount: S Amount Paid 43-2's-- ;Z Paym t Date Payment Type Invoice # Check # `71�- Received By: If i EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 0