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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNiIIiOP ERATOR CHECK if BILL/G ADDRESS FACILITY NAME EMPLOYEE #: SITE ADDRESS Scree umber Direction SERVICE CODE: Street Name Cit EipCode HOME Or MAILING ADDRESS Different from Site Address) Street NumberF /Street Name CITY STATE ZIP PHONE #1 E I ) APN # LAN;7 APPLICATION # PHONE #2 EXT.S ) DISTRICT LOCATION CODE CONTRAICTOR / SERVICE RtOUESTOR REQUESTOR CHECK if BILLING ADDRESS O BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX # CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undo' geed property business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ); IRONMGNTAL H(ALTI GPARTM�NT hourly charges associated with this project or activity will be billed to me or my business as / ntified on this form. I also certify that I have prepared this app ' ation and that the work to be per COUNTY Ordinance Codes, Standards, VATE and FEDERAL laws. APPLICANT'S SIGNATURE: will be done in accordance with all SAN JOAQUIN DATE: PROPERTY/ BUSINESSOWNF.R❑ OPERATOR/ MANAGER ❑ OTIIERAUTIIORI7.E\datad/o If APPLICAN- s not the BILLING PARTY proof of authorization to sign is Title AUTHORIZATION T ELEASE INFORMATION: When applicable, I, the ownr of the property located at the above site address, reby authorize the release of any and all results, geotechnicr environmental/site assessment informatiotl to the N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as sailable and at the same time it is provided to me o y representative. TYPE OF SERV/REQUESTED: REQUESTED: COMMENTS: 7 APPROVED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: <HD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02