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V MW • • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Gc,� FACILITY ID # ;SERVICE REQUEST # s�-cv � C)Y-, (el RECE T o V7 OWNER /OPERATOR CO CHECK if BILLING ADDRESS C- © 2005 ACCEPTED BY: -' ` FACILITY NAME 1 ASSIGNED TO:MPLOYEE #: C SITE ADDRESS �3 - PIE: rZ D I FS Street Number Direction Payment Type Street Name Check # Ci ZI Code HOME or MAILING ADDRESS (If Different from SiteAddress) 1 Street Number Street Name CITY � C� r STAT/EZIP PHONE #1 ` Exr., APN # LAND USE APPLICATION # PHONE #T EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME j /� PHONE# ExT. HOME Or MAILING ADDRESS FAX # 001I�I 1 y2 CITY C STATE \ ' G ZIP �� _2 U 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, Standrds, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT Z l t A �,S If APDL/CANT i no 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 DEPARTM71fsoon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: RECE T VE D 2005 ACCEPTED BY: -' ` EMPLOYEE #: N �il�d ASSIGNED TO:MPLOYEE #: C Date Service Completed (if already completed): SERVICE CODE: PIE: rZ D Fee Amount: Amount Paid - Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)