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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAMEG ` c,1 a /- FACILITY ID # SERVICE REQUEST # FOA -7�,c-K 7��o0 ?3 OWNER /OPERATOR c0.rtG /� / vez- CHECK If BILLING ADDRESS `/II FACILITY NAME ! , r� rz- J oc-co LL j t Y SITEADDRESS JI EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already Completed): Street Number Direction P /R: Street Name Cit ZI Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Date rI _ L Z Payment Type W5 A� I Invoice # I C # `C� O Zv Street Number Street Name CITYGy G STATE /` ZIP PHONE#1 Exr. APN # LAND USE APPLICATION # (2-01 ) q111- 2fF-C PHONE#2 EXr. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAMEG ` c,1 a /- PHHOOI E'er. NE# -2f HOME Or MAILING ADDRESS �c% � I � S -r FAX# CQ y STATE C ZIP ?q tG 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 laws. APPLICANT'S SIGNATURE: DATE: � j/zJ of L - PROPERTY / BUSINESS OwtNE OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BlLL/NG 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 assesssp�lTCp, t information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at PAND& tM11 IS provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: 0 4 2M COMMENTS: MAY SAN N COLIN' ENVIRONIMENTAL HEALTH DEPARTME d Tian Cheo< J ACCEPTED BY: JI EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already Completed): SERVICE CODE: �1 3 P /R: Fee Amount: 'Q Amount Paid Payment Date rI _ L Z Payment Type W5 A� I Invoice # I C # `C� O Zv 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003