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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME l �� FACILITY ID # SERVICE REQUEST # FAX# CITY -✓ STATE ZIP S Roo � 3c�3 OWNER/ OPERATOR _ M Ql t O I , G S CHECK If BILLING ADDRESS FACILITY NAME E i C ��—e ct v -n � J L C, SITE ADDRE r ACCEPTED BY: V ` •� l Street Number Dlr U.. Stree! Name DATE: 5 HIR City Zip Cada OME or MAILING AD RESS (If Different from Site Address) R,c t 6 � ' `' C�� Fee Amount: ,V U Amount Paid Street Number Payment Date Street Name CITY �-r� G S ATE ZIP PH�OONNEnE�#1 ExT• APN # Received By: LAND USE APPLICATION # PHONE #2 E%r. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTORt� U r Q CHECK If BILLING ADDRESS BUSINESS NAME l �� PHONE# ! HOME Or MAILING ADD - S '1 FAX# CITY -✓ STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property orbitisiness owner, operator or authorized agent of same, aclutowledge 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 STATf and FEDERAL laws. APPLICANT'S SIGNATURE: t DATE: PROPERTY/ BUSINESS OWNER❑ OPE TOR/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 tt— Same time it is provided to me or my representative. /P TYPE OF SERVICE REQUESTED: V CE COMMENTS; MA f1Y r ACCEPTED BY: V ` •� l EMPLOYEE#: DATE: 'y ASSIGNED TO: (� EMPLOYEE M I' }L DATE: 5 HIR Date Service Completed (if already completed): SERVICE CODE: P / E: O� Fee Amount: ,V U Amount Paid Payment Date Payment Type Invoice # G,1SR i .L) L 0Cd--t Received By: EHD 48-02-025 REVISED 11/17/2003 M SR FORM (Golden Rod)