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SAN JOAQUINP-t.YOUNTY EWIROI�LMENTAL HEALTh..oEPARTMENT SERVICE RL'UEST FACILITY ID# SERVICE REQUEST# EFAmm Business or Property O' N CA 21- I OPERATOR CHECK If BILLING ADDRESS❑ ZJC.1�P -pA/FJJJJ 1�f�-J IL.Le �/J(, NAME - SITE ADDRESS 3�+'�3 ZvL„t�L�1'1y1� IL'l'�l/t-V� SCOULI Street Number Dirctlion Street Name C' Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name STATE ZIP CITY Ear. P(HONE#1) Al2P4N# LANDUSE APPLIN#CAIO BOS DISTRICT Exr. J LOCATION CODE PHONE /vE PHONE#2 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ^) S.( a )acIL �^v.la E 1 C,_ CHECK if BILLING ADDRESS l��Fz"DS Ear. PHONHONE# BUSINESSNAME FAx If Q HOME or MAILING ADDRESS O O<) ( 0 , CITY S O t/ I V 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 ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, ATE and FEDERAL WS. APPLICANT'S SIGNATURE: .*�. DATE: PROPERTY/BUSINESS OWNER[] O TOR/MANAGER OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as i s available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: s r COMMENTS: / 173/01f 12/1S RECEIVED NOV 9 2004 �-or � JU Qom/ SAN JOAOUIN COUNTY 9Ud1CJ, I ENVIRONMENTAL HEALTH D P ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: 1 EMPLOYEE#: 7y DATE: Date Service Completed (if already completed): SERVICE CODE. S Z z PIF: Fee Amount: / - _ Amount Paid _ Payment Date - Payment Type Invoice# Check# - Received By. EHD 48-02-025 SR FORM(Golden Rod)