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x NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE # EXT. ( ) HOME or MAILING ADDRESS SERVICE REQUEST # SAIV j yF L�tiQ NMFNTVIVJy Aj EPjR y NT GOA 0 EMPLOYEE #: 2 J 0 s-7--�)y ASSIGNED TO: / EMPLOYEE #: DATE: Date Service Completed OWNER/ OPERATOR �/ SERVICE CODE: CHECK If BILLING ADDRESS El S�Tj � 2 /� � /� �� Amount Paid ` , 61 j FACILITY NAME RncJ Invoice # / SITE ADDRESS �g�'G �c�'n �sy C/L, ✓ ��r c/ j / s�CCK' Lt7� 95 Street Number Direction Street Name city Zip Code HOMErRr MAILING ADDRESS (If Different frym Site Address) r r m. '10 3e � , Street Number Street Name CITY STATE ZIP r/�3 L 1� A iKftf ("'q PHONE#1 EXT. APN # LAND USE APPLICATION # ('7--?) -2 g 6 - 71 7 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME viyrRy PHONE # EXT. ( ) HOME or MAILING ADDRESS FAX # SAIV j yF L�tiQ NMFNTVIVJy Aj EPjR y NT ACCEPTED BY: CITY n 2 STATE ZIP y S. C_ l! �� n �'f 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 th the work to by performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE,and'1~EY APPLICANT'S SIGNATURE:rz,�? DATE: C) � X, 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and time it is provided to me or my representative. ! N% % TYPE OF SERVICE REQUESTED: OCT COMMENTS: Ali��`� / SAIV j yF L�tiQ NMFNTVIVJy Aj EPjR y NT ACCEPTED BY: / EMPLOYEE #: 2 J DATE: ASSIGNED TO: / EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: fl'l f / Fee Amount: v� Amount Paid ` , 61 j Payment Date Payment Type Invoice # Check # 3 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM'(Golden Rod)