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a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP 2go6 T� i r�� '� c� s �1 -zq 6 �� r, l � ►�, �'k OWNER/ OPERATOR ❑ DATE: � C 2 ASSIGNED TO: Y CHECK if BILLING ADDRESS FACILITY NAME DATE: /l /�2O Date Service Completed (if already completed: SITE ADDRESS 2,?6 SERVICE CODE: v P / E: ZI�Z /� �Q �� (j��,J 19W N { /Name Amount Paid tea.—" Payment Date (l R Street Number Direction Invoice # I Street 3 l5 Cit Zi Code H E or MAILING QA ADDRESS (If Differ t from Site Addr Street Number r Street Name CyTY '^ STATE/`� A ZIP (�yJ A� PHONE # j Exr.ApN # .�70 © � J G L tb LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ` f 0�. 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 OUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. PPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ PAVnML-p. If APPLICANT is not the BILLING PARTY, proof of authorization to sign: is required "/tie �� AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property o 90at the above site address, hereby authorize the release of any and all results, geotechnical data and/or envirot{ttki#al sOez��ssment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availably.and at the a ne it is provided to me or my representative. QUW Cot1N TYPE OF SERVICE REQUESTED:L4 :Z67nT PART. COMMENTS: ffe j 0 Cq- � o g = Se��' C r S� bac �� 2go6 �w ot ►l C/r tl 3 ��ci� a � i r�� '� c� s �1 -zq 6 �� r, l � ►�, �'k ACCEPTED BY: EMPLOYEE#: I / V DATE: � C 2 ASSIGNED TO: Y EMPLOYEE #: DATE: /l /�2O Date Service Completed (if already completed: SERVICE CODE: v P / E: ZI�Z Fee Amount: --a) Amount Paid tea.—" Payment Date D .2 Z Payment Type 0. Oki Invoice # I 3 l5 Received By: :�;4 EHD 48-02-025 REVISED 11/17/2003 w7 1/ SR FORM (Golden Rod)