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SAN JOAQUIN VNTY ENVIRONMENTAL HEALTH IVRTMENT SERVICE REQUEST J ��Ud3Zf Type of Business or Property FACILITY ID # SERVICE REQUEST # CHECK If BILLING ADDRESS AJ BUST NAME ^P�(,th/�^` OWNER / OPERATOR EXT. E .� CHECK If BILLING ADDRESS FAX#Y`n �y FACILITY NAME -- STATE 6,A SITE ADDRESS ASSIGNED TO: e--� _ EMPLOYEE #: / DATE:PP' Date Service Completed (if already completed): SERVICE CODE: 2M40Street Number Direction Street Name Payment Type City 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 # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR RE?U STOR / SAN JOJDE CHECK If BILLING ADDRESS AJ BUST NAME ^P�(,th/�^` PHON EXT. E .� HOME Qf MAILING ADDAESS FAX#Y`n �y CITYj �p STATE 6,A ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al! 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 JOAQI liN COUNTY Ordinance Codes, Standards, TE FED RAL la APPLICANT'S SIGNAT UR E: DATE: PROPERTY / BUSINESS 0\0'NER l.a _� ' OPERATOR / INI kNAGER ❑ OTHER AUTHORIZED AGENT ❑ /fAPPLICAN7' is not 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 locatfgAYMENT above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site aSR'EjWjVED information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPARTMENT as soon as it is available and at the same UGL II 4 20�� provided to me or my representative. TYPE OF SERVICE REQUESTED: w�t-(� SAN JOJDE COMMENTS: � � ' HEALTH Ji ACCEPTED BY: dL L U C t EMPLOYEE ��/ DATE: r ASSIGNED TO: % EMPLOYEE #: / DATE:PP' Date Service Completed (if already completed): SERVICE CODE: © d Fee Amount: 37Amount Paid � 37�1 DD Payment Date Payment Type Invoice # Check # b�o — Receiv EHD 48-02-025 C� ✓"� LTk r/ SR FORM (Golden od) REVISED 11/17/2003 COUNTY ENTAL ARTMENT