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lot SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property -F FACILITY ID # SERVICE REQUEST # BUSINESS NAME ! tQg� 1 r ` J 7 JR ce jvp" MAY SAN J 1 ��2 11471kRO/yME DUNIy ( HOME Or MAILING ADDRESS Yl S ptCe CT A44 7E -4(AX I� OWNER/ OPERATOR # ) �] STATE C 00jr ZIP 5 Date Service Completed (if already completed): CHECK If BILLING ADDRESS LTJ FACILITY NAME J- �4 . h, Jr— P / E: SITEADDRESS '7S61 Amount Paid y Payment Date street Number Direction street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1-2 Received By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (51()' - 74 Sr PHONE #2 EXT• ( ) BOS DISTRICT —7LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 0 CHECK If BILLING ADDRESS BUSINESS NAME ! tQg� 1 r ` J 7 JR ce jvp" MAY SAN J 1 ��2 11471kRO/yME DUNIy PHONE # EXT. 16 q - HOME Or MAILING ADDRESS Yl S ptCe CT A44 7E -4(AX I� DATE: ,j � v TMENP # ) CITY STATE C 00jr ZIP 5 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 FE AL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ O ATOR / MANAGER ❑ OTHER AUTHORIZED AGENrcc 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 the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: V JR ce jvp" MAY SAN J 1 ��2 11471kRO/yME DUNIy ACCEPTED BY: EMPLOYEE #: &-jam e2 DATE: ,j � v TMENP ASSIGNED TO: S� ` EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: Amount Paid y Payment Date �� (22 Payment Type L Invoice # eck J 1-2 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003