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SAN JOAQT"N COUNTY ENVIRONMENTAL HEAT "'H DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # F'��`i ��r1F � I - SERVICE REQUEST It. PHONE# Exr' HOM LING DDFWSIS FAx# ( 13'-63 OWNER/ OPERATOR STATE ZIP DATE: &I10/ T!ho CHECK If BILLING ADDRESS FACILITY NAME 2'a3 DATE: ! � � e SFRVICECODE:�a SITE ADDRESS Fee Amount: 2- 301 CIO 0 Ave 4eem /�4 �` [/Zip 13* Street Number Direction w Name Received By: C' Code HOME Or MAILING ADDRESS (If Different from Site Ad'dress) Street Number Street Name CITY STATE ZIP PHONE#I EXT. APN# LAND USE APPLICATION# PHONE#ZET. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR _ CHECK if BILLING ADDRESS F'��`i ��r1F � I - BUSINESS NAME PHONE# Exr' HOM LING DDFWSIS FAx# ( 13'-63 CITY 14 10aA., STATE ZIP BILLING ACKNONXEDGEMENT: 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, Standard S, STAT FEDERAL laws. APPLICANT'S SIGNATUREDATE: ZZ tV PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT iS not the B/LL7NGPARTY 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 environmentallsite assessment information t0 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. TYPE OF SERVICE REQUESTED: 1169 q,/%1 F'��`i ��r1F � I - COMMENTS: V N0� DISCARD DO t • FI -I �L-IVEL) JUN N COUNTY SAN R.OCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: (0 ( DATE: &I10/ T!ho ASSIGNEDTO: EMPLOYEE #: 2'a3 DATE: ! Date Service Competed (if already completed): SFRVICECODE:�a PIE: 360 Fee Amount: 2- 301 CIO Amount Paid 'd b Payment Date Payment Type Invoice # Check # S y %k V Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003