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SAN JOAQUIN�UNTY ENVIRONMENTAL HEALTH*PARTMENT SERVICE REQUEST Type of Business or Property r p1 CHECK if BILLING ADDRESS E] FACILITY ID # SEEjR,VIC�E1 REQUEST # OWNER/ OPERATOR HOME or MAILING ADDRESS 1 , / C� gT�'t�+ FAX # (916) CHECK If BILLING ADDRESS FACILITY NAME ^ W (Lk ^ �n SITE ADDR SS 1 Street Number Direction �\� �; �� Street Name �o p�� citv QP3aDL Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number ACCEPTED BY: Cj L I A— Street Name CITY DATE: I G S ASSIGNED T0: j �,(�S C7� STATE ZIP PHONE #1 ( ) ExT. Date Service Completed (if already completed): APN # LAND USE APPLICATION # PHONE#2 ( ) EXT. Fee Amount: 1lcj . v 0 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR w r p1 CHECK if BILLING ADDRESS E] BUSINESS NAME 1 r PHONE# UJ I ExT. HOME or MAILING ADDRESS 1 , / C� gT�'t�+ FAX # (916) J 63r- i31� CITY "t"'C-\&-U STATE (Lk ZIP (�'6 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, ATE FEDERAL laws. APPLICANT'S SIGNATURE: DATE: o4 PROPERTY/ BUSINESS OWNER ❑ O RATOR /MANAGER ❑ OTHER AUTHORIZED AGENT14 5'�l�'� If APPLICANT is not the BiLLINGPARTI, 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. PffigZF�ERVICE REQUESTED: uS'r" COMME d 0J LFtT Pa0\N gP ENv\P 0 PPR �o N ACCEPTED BY: Cj L I A— EMPLOYEE #: 22 21 DATE: I G S ASSIGNED T0: j �,(�S C7� EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P i E: oZ3 •U Fee Amount: 1lcj . v 0 Amount Paid 11 —177. D D Payment Date ( p—S Payment Type Invoice # Check # /-7 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)