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SAN JOAQU&OUNTY ENVIRONMENTAL HEALT&PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 1- -T-7ro o SKo E' FAX# CITY STATE ZIP S o a io goz 5-9 OWNER / OPERATOR CHECK If BILLING ADDRESS S e r ve,-, r r ASSIGNED TO: l ^ t . ` A -F— 7-00 FACILITY NAME--o (ry f -� l EMPLOYEE #: SITE ADDRESS ) L o 2 P, Do SERVICE CODE: o G ( 0 Street Number Direction Street Name to 1 it Zin Code Payment Date (OI1 PHONE #'I ExT. APN ## LAND USE APPLICATION # (9t.70 � 9 -7 r 3 S 3 131-6-70 —0 11 PHONE #2 ExT. BOS DISTRICT ct, 1 1[ LOCATION CODE ( . a CONTRACTOR / SERVICE REQUESTOR REQUESTOR �� r- ��l /� CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX# CITY 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 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, STATE and F ERAL laws. APPLICANT'S SIGNATURE- DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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. /w�ties � ■s i TYPE OF SERVICE REQUESTED: Go � � :H7IVit:N r REGEr COMMENTS: ., o OCT14 C ` SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: Nom( EMPLOYEE M 7 i -7 U127 DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: o G ( P 1 E: („�(� 3 Fee Amount: Amount Paid- —" Payment Date (OI1 Payment Type CA6k> Invoice # Check # Received B . 6 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003