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SAN JOAQUI' 7OUNTY ENVIRONMENTAL HEALT 7EPARTMENT SERVICE BEQUEST Type of Business or Property F-�7ACILITY ID# SERVICE REQUEST# 54&--33s7- OWNER/OPERATOR / CHECK if BILLING ADDRESS� FACILITY NAME (/L SITE ADDRESS 51�50 / Ia (? f-j O / Street Number Direction Stre t Name Z1 Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#t APN# LAND USE APPLICATION# (z-o ) 00-7 - 3/0 - PHONE#2T• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR / / CHECK((BILLING ADORES R3 BUSINESS NAME J PHONE# 2 _ Z •zo 33t+-G5Z3 HOME or MAILING ADDRESS FAX If �j 3�(' - z�l/ (�9) 't CITY O STATE / LP Z BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvTRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this fomL 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. o APPLICANT'S SIGNATURE: //yrs gyp' DATE: PROPERTY/BUsiNESSOWNER❑ '04FRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0, JfAPPLICANT is not the B7LLINGPARTY 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. N TYPE OF SERVICE REQUESTED: L R FEIVED CDRRENTS: a AUG 2 2005 SAN JOAQUIN COUNTY ENvIRONMFNTAL JiEALTH DEPAR MENT ACCEPTED BY: EMPLOYEE#: d (� 7 DATE: b - 2_ ASSIGNED TO: EMPLOYEE#: ! DATE: . Date Service Completed (if already completed): SERVICECODE. P 1 E: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: SR FORM(Golden Rod)