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SAN JOAQ*COUNTY ENVIRONMENTAL HEA* DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS El <br />FACILITY NAME <br />EMPLOYEE #: <br />SITE ADDRESS <br />Street Number <br />I Direction <br />SERVICE CODE: <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY STATE ZIP <br />I31I.11.,ING ACICNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Slandart1s, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY / BUSINESS OWNER 11 OPFRATOR / MANACER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLICANT APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AU'rHOR1ZAT10N TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTii DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />APPROVED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />