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SAN JOAQUIN RUNTY ENVIRONMENTAL HEALTH D0ARTMENT SERVICE REQUEST Type of Business or Property N FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # BUSINESS NAM R� PHO E# EXT. OWNER / OPERATOR ) HOME or AI INGADDRE S COU HEA TH ` CHECK if BILLING ADDRESS ❑ CITY STATE ZIP FACILITY NAME ACCEPTED BY: (� � _' D CC�"�Ct yi G'� C EMPLOYEE #: S' DATE: S � SITE ADDRESS EMPLOYEE #: 3 DATE: 3 O L)— Date Service Completed (if already completed): Date SERVICE CODE: Street Number Direction a d Payment Date Payment Zi Code HOME or MAILING ADDRESS (if Different from Site Address) Invoice # Check # /— f^ Received By: Street Number J Street Name CITY / i $TATE ZIP . ;72 PHONE #1 ExT• APN # LAND USE 4PLICATION # PHONE #T ( ) ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR N T CHECK if BILLING ADDRESS MENTS: BUSINESS NAM R� PHO E# EXT. SA N �OAQUIN ) HOME or AI INGADDRE S COU HEA TH SAN JOAQUIN COUNTY (AX# r s 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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDE laws. APPLICANT'S SIGNATURE: / DATE; PROPERTY / BUSINESS OWNEROPERATOR /MANAGER 13 OTHER AUTHORIZED AGENT IfAPPLIC is not the BILL/NG 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. oA TYP Es��K2-)EC N T ,' AYMENT MENTS: JU� 13 2005 R� •� SA N �OAQUIN JUN 1 0 2005 �) COU HEA TH SAN JOAQUIN COUNTY D PARTMENT ENVIRONMENTAL DEPARTMENT ACCEPTED BY: (� � _' D CC�"�Ct yi G'� C EMPLOYEE #: S' DATE: ASSIGNED TO: J S EMPLOYEE #: 3 DATE: 3 O L)— Date Service Completed (if already completed): Date SERVICE CODE: P / E: 2,, -,- ✓,C,- Fee Amount: Amount Paid d Payment Date Payment Payment Type �- Invoice # Check # /— IR. Received By: J EHD 48-02-025n'"="" REVISED 1111i/2003`�� SR FORM (Golden Rod)