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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # OWNER / OPERATOR S' CHECK if BILLING ADDRESS FACILITY NAME � � EZ0 e, c � SITE ADDRESS /1 Street Number Direction r1 l� n r6I. S eet�n Na - l� 1 lX- �jS�tjme [� itu l�V`v� 1l ZI C(o_jdle,- HOMEM MAAII/L,yI�N13 ADDf RES If Different from Si a Addr SO /{J" " �tM Street Number Street Name CITY1 'AP lJ _ 9 STATE ZIP 01�• PHON EXT• (10 Z`-.� --y q ACCEPTED BY: N # - - s LAND USE APPLICATION # sl 1--'-L�71 PHONE #2 EXT. ( ) rvt e"1 ✓ BOS DISTRICT `� LOCATION COPE CM CONTRACTOR / SERVICE REQUESTOR REQUESTOR ] �� I I CHECK if BILLING ADDRESS O l 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 applicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE nd ERAL I� APPLICANT'S SIGNATURE: ATE: PROPERTY/ BUSINESS OWNER ❑ OPE TOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ PAYMENT If APPLICANT is not the BI ING PARTY proof of authorization to sign is required Title RECEIVED 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 env ironmental/siA aUs2422 information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is COUNTY provided to me or my representative. SAN JOAQUIN CTAL ENVIRQ HEALTH DE PAR ENT TYPE OF SERVICE REQUESTED: S ('V COMMENTS: ` ,� � /� � � � EZ0 e, c � v��- C-) 9 ACCEPTED BY: EMPLOYEE rvt e"1 ✓ DATE: ZZ ASSIGNED TO: - EMPLOYEE M DATE: Z Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: — -- Amount Paid �� Payment Date - , j Z Payment Type Invoice # Check # o , ' Received By: j .' EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003