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FEB/07/2008/THU 05:13 PM RHL'-sign Group FAX No,916 771 5 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST P. 006 CONTRACTOR / SERVICE REQU'ESTOR REQUESTOR 4 BusmEss NAME [�{ Home or MAILING ADDRESS CITY .11 i I . — CHECK If &L G Ab ESS exr. �Zo l 'N STATE .-AA zip OWLEDGEME : I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvaoNNENTAL HEALTH AEPARTMENT hourly charges associated with this project or activity will be billed to the or my business as identified on this farm. 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, STAT and FEDP_ laws. APPLICANT'S SIGNATURE: DATE:'�'O� PROP¢RTY / BUSINtS3 OWNER❑ OPERATOR / MANAGER OTHER AUTHOR[zED AGENT If APPLICANT is not the BILLING 1°AItTY proo at tlzorizatlon to sign is required Ting AUTHORIZATION LEASE INFO IATION: '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 ENVIRONKENTAL HEALTH DEPARTN ENT as soon as it is available and at the Same time it is provided to me or my representative, TYPE of SERVICE REQuESTEO: COMMENTS'�� ACCEPTED BY: Assi(3wwo V, Date Service Completed (if already complated): Fee Amount: et --7Z1-c Amount Paid Payment Type I/ ' 'I rnvolce X EHO 48-02-025 REVISED 11117/2003 �r EMPLOYEE : Zat EMPLOYEE#: SERVICE CODE: C�jk. 00 Payment Check , FFOO Vel FEB 7 zoos SAN JOAQUIN COUNTY ENVIRONMENTAL EALTH DEPARTMENT DATE: DATE! _/ - L PIE: 2 � Recei ed y: 6 SR FORM (Golden Rod)