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SAN .JOAQUI OUNTY ENVIRONMENTAL HEAL`I EPARTMENT 5' ` -/ < y� SERVICE REQUEST ,� s ' --Zp& Type of Business or Property CHECK if BILLING ADDRESS E] ' FACILITY ID # COMMENTS: SERVICE REQUEST # HOME Or MAILING ADDRESS� ` FAX# okq) +60' J &3(f a 9qv�-(.. CITY tet, r -STATE ZIP OWNER / OPERATOR Ynb U 1 CHECK if BILLING ADDRESSYna,-,he,4kr FACILITY NAME 7 HEALTH DEPARTMENT APPROVED BY: ot-1 C:'E f EMPLOYEE #: / G -f DATE: r3 SITE ADDRESS ) tV I f I 1 Date Service Completed (if already completed): Street Number DireWction " ' Street Name Payment Type Invoice # Check # g � Received By: HOME or MAILIN RESS (If Different from Site Address) Street Number eet Name CITYE ZIP ua,4 ©llV�� PHONEel EXT. APN # LAND USE APPLICATION # P E 2 EXT. Qy� (06-1 Z-3 BIDS DISTRICT LOCATION CODE -J /I CONTRACTOR / SERVICE REQUESTOR REQUESTOIrA, ((� CHECK if BILLING ADDRESS E] ' BUSINESS NAME t COMMENTS: PH E ! _ ^ (X 1Exr. HOME Or MAILING ADDRESS� ` FAX# okq) +60' J &3(f a 9qv�-(.. CITY tet, r -STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-I 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 thi&,ATE,and ication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standard FED -RAL laws. APPLICANT'S SIGNATURE: DATE: DATE: l �fo� PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTIIEIt AUTHORIZED AGEN-I>/ if APPLICANT 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 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. n�vnAENT TYPE OF SERVICE REQUESTED: S% CEIU COMMENTS: 13 2004 �, COUNTY SAN JOAQUIN ENVIRONMENTAL HEALTH DEPARTMENT APPROVED BY: ot-1 C:'E f EMPLOYEE #: / G -f DATE: r3 ASSIGNED TO: EMPLOYEE #: �� DATE: Date Service Completed (if already completed): SERVICE CODE: 1 q 16 P I E: Fee Amount: `7 - �, Amount Paid D Payment Date Payment Type Invoice # Check # g � Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02