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SAN JOAQUWouNTY ENVIRONMENTAL HEALT*PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE# En* 2`3r SERVICE REQUEST # OWNER / OPERATOR CITY Z-oC ' 0/1 JD STATES /1 21P �� ❑ EMPLOYEE #: DATE: Date Service Completed (if already completed): CHECK if BILLING ADDRESS r P / E: 6 Fee Amount: �v CAP i FACILITY NAME �— Payment Date � SITE ADDRESS if Invoice # p,� 16-10 �yy� ILo G v-!� �v(� 17 99.3-7.- Street Number Direetion 1 4 tree>.t� city Zip Code HOME or NAILING ADDRESS (lf Different from Site Address) _ Fl —I 111P 0 ` Street Number 1 K.� � �r'c I eet Name CITY STATE ZIP �1� L_ J PHONE#1 ExT• APN # LAND USE APPLICATION # ('Zell L4 bj - 'Zq 2-6 10 —` PHONE#2 Exr. 1 BIDS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR�� f U V / CHECK If BILLING RE C�A/ BUSINESS NAME _ �Ci fZS , PHONE# En* 2`3r HOME or G ADD ESS ,/% /Zo5 -1c C T pl -A FAX # ( ) CITY Z-oC ' 0/1 JD STATES /1 21P �� 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 law APPLICANT'S SIGNATURE: DATE'G' GSI 3 PROPERTY / BUstNESs OwNER ❑ OP OR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLIC_4AT is not the BILLING P_4RTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. I TYPE OF SERVICE REQUESTED: IV COMMENTS: ilECEVvED FEB, 4 8 ?'aS SAN JOPE�cout • . ACCEPTED BY: EMPLOYEE #: H ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CoDE: '�/7/ P / E: 6 Fee Amount: �v CAP i Amount Paid � �— Payment Date � Payment Type Invoice # Check # Received By: E'C/ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003