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JI� LA SAN JOAQUIN rOUNTY ENVIRONMENTAL HEALTV nEPARTMENT SERVICE REQUEST Type of usiness or Property FACILITY ID # PP hl _ EXT. c } SERVICE REQUEST # FAX# -7-7 33 FWNER) OPERATOR. I ;,� �/� / , � � l t ENVIRONMENTAL CHECK if BILLING ADDRESS ❑ FACILITY NAME ACCEPTED BY: EMPLOYEE #: V (/ 1 v ll 1 K ASSIGNED TO: SITE ADDRESS �on L'L - Date Service Completed (if already completed): 4k"' ` Street Number Dife TT�7? CL C Street Name Payment Type t/ Invoice # Zip Cod HOME Or MAILING ADDRESS (If Different from Site Address) Received By: 7 Street Number T Name CITY LL i�, L o- ( L STATE ZIP ) 6 :3. P(HOfE'A1) q (4 I r �� q`/ EXT. 7PN11 LAND USE APPLICATION# PHONE#2 ExT• (6) - O ,3 BOS DISTRICT --7LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 1 1 CHECK if BILLING ADDRESS BUSINESS NAME PP hl _ EXT. c } HOME Or MAILING ADDRESS � /�` � f �• FAX# CITY /��.qv 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 COUNTY Ordinance Codes, Standar s, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: (, /�l/U:DATE: "-7gv-e><5 "I PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT \ �, (f t' iv 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. pA MENT EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) RE TYPE OF SERVICE REQUESTED: GJ 6-1 COMMENTS: FEB 4 ZQ�' SAN JOADUIN COUN'II' ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: V (/ 1 v ll 1 DATE: _ 1 n v ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: Ig P 1 E: 30 Fee Amount:Z Amount Paid TT�7? CL Payment Date n � ID S Payment Type t/ Invoice # Check # U� Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)