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F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQUESTOR REQUESTOR JKB Living, Inc. BUSINESS NAME Fina by John.Surla HOME or MAILING ADDRESS P.O. Box 2998 CITY Turlock CHECK if PHONE # FAx # (760 )214-4555 STATE ZIP BILLING ACKNOWLEDGEMENT: 1, 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, STA and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER El OPERXIOR / 'R -❑ OTHER AUTHORIZED AGENT ErCommunity Development Director IfAPPLICANT is not the BILLING PASTY 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 DEPAR'T'MENT as soon as it is available and at t1Asame time it is provided to me or my representative. J6" /I TYPE OF SERVICE REQUESTED: 0JU ck-. 1LAZUi' COMMENTS: U� 201? IDAQ _ U�N 7YpE cyF4CTliy4�� r ACCEPTED BY: EMPLOYEE #: _ �7 DATE:rz ASSIGNED TO: EMPLOYEE #: DATE: '6 Date Service Completed (if already completed): SERVICE CODE: a—, ZJ PIE: Fee Amount: iH rJ- Amount Paid �T�U. �� Payment Date 23 Payment Type U_ Invoice # Check # 372 Recei ed By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)