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SAN JOAQUSOUNTY ENVIRONMENTAL HEALTH *ARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE# EXT. ,FA- 0003(olb 1 5"0 559Zf6 2 -4o*-) HOME or MAILING ADDRESS DATE: l O� FAX # Ajtr OWNER/ OPERATOR (RCS() Cl) -oz/-4 CI STATE C ZIP Z 1Z SERVICE CODE: 09 9 CHECK If BILLING ADDRESS J Ruic> Fee Amount: ^ 7 � � Amount Paid 00 FACILITY NAME Payment Date it 0 (p -� -ILAu C s SITE ADDRESS(=137'j' Received By: i j7pnlflt `Jt�C-ICTcy.� C* 2.l Z' Street Number Direction Street Name Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # C1T& Aolo Uqz b2?0 c3 PHONE #2 EXT. BOS DISTRICT LOCATION CODE` CONTRACTOR / SERVICE REQUESTOR REQUE$TOR CHECK if BILLING ADDRESS VimIcL N LLO C BUSINESS NAME PHONE# EXT. C APPROVED BY: C1 C 2 -4o*-) HOME or MAILING ADDRESS DATE: l O� FAX # Ajtr EMPLOYEE #: —�S p© (RCS() Cl) -oz/-4 CI STATE C ZIP Z 1Z 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, n FEDERAL law . APPLICANT'S SIGNATURE: DATE: /fl S PROPERTY / BUSINESS OWNER ❑ OPERATO NA R OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING roof 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. TYPE OF SERVICE REQUESTED: COMMENTS: APPROVED BY: C1 C EMPLOYEE #: $ g DATE: l O� ASSIGNED TO: _ L E EMPLOYEE #: —�S p© DATE: Date Service Completed (if already completed): SERVICE CODE: 09 9 P I E:,) 36 f Fee Amount: ^ 7 � � Amount Paid 00 Payment Date it 0 (p Payment Type Invoice # Check # 30 ( �% Received By: U vZK TN' vu F N T 4f Q- q'� EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FORM vuf-