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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # SERVICE REQUEST# HOME Or MAILING ADDRIISS 5- FAX# ( ) CITY Ge /, STATE �� ✓/ ZIP U� VO N/l sem -3 ML— OWNER / OPERATOR CHECK If BILLING ADDRESS N? ACCEPTED BY:Al FACILITY NAME EMPLOYEE #: DATE: 2 ` ASSIGNED TO: I, DATE: lr Date Service Co pleted (if already completed): SITE ADDRESS Street Number Direction Fee Amount: Amount Paid - ten/ }(G / "ZI COC HOME or MAILING ADDRESS (If Different from Site Address) Payment Type 0, at Invoice# GG ReceivedBy- Street Number Street Name CITY / TATE ZIP i e G6, PHONE ##1 R }/ EXT. �l � I �V • S APN # LAND USE APPLICATION # yr)� PHO\NE#2 Em I ) BOS DISTRICT LOCATION CDOE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK It BILLING ADDRESS BUSINESS NAME II PHONE# EXT, HOME Or MAILING ADDRIISS 5- FAX# ( ) CITY Ge /, STATE �� ✓/ ZIP U� 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 FEDERAL laWf. APPLICANT'S SIGNATURE: / LZA c—✓� DATE: ✓ A' Z�, ?ez l' �� PROPERTY/ BUSINESS OWNERIN%OPERATOR/ MANAGER ❑ OTHERAUTHORIZED AGENT 11 e I IjAPPLtCANT is nat the B2L/NG PAR 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. PAYA.II!.a TYPE OF SERVICE REQUESTED: EC COMMENTS: VO N/l Pm Flq UN EAL yRO OEPA, M N? ACCEPTED BY:Al EMPLOYEE #: DATE: 2 ` ASSIGNED TO: EMPLOYEE DATE: /J Date Service Co pleted (if already completed): SERVICE CODE: P I Fee Amount: Amount Paid - 5a Payment Date 2,& 121 Payment Type 0, at Invoice# 28t�c1�8e-'-(p ReceivedBy- EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003