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09/26/2008 FRI 16:49 FAX 2094683433 SJC EHD 0007/007 v : 0 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR,rMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # COMMENTS: ®/ OR 97 v LJkw� CHECK If BILLING ADDRESS FACILITY NAME raw SAN JOAQUIN COUNTY SITE AD R SS� Street Numher Direction e etlb HOME or MAILING ADDRESS (If Different from Site Address) ACCEPTED BY: EMPLOYEE #: Street Number Street Name CITY STATE zip P oNE#1 _ C J EXT. APN # LAND USE APPLICATION # PHONE #2 Exr. t ) SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR BILLING A,CKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spect -ILENVIRONMENTAL HGAI;1'Ii Di.;PAKTML:N'i' hourly charges associated with this project or activity will be billed to me or my b ness as i ratified on thys.totm. I also certify that I have prepared COUNTY Ordinance Codes, Stand be performed will be done in accordance with all SAN JOAQUIN APPLICANT'S SIGNATURE: PROI'I'JtTY / 13 USI NFSS OWN 1,1113 PF11 TOR / r .lila ❑ THFn Au'rnoitl/..EA AGFNT341 1 f iIPPLiCAN't' is not the i3/l l Lvc 11;I m proof of authorization to sign is required Tfrl e AUTHORIZATION M 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 re-SURS, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN'I'At, HEAi,'ni DEPARTML'N'r as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: CHECK if BILLING AoDRES 011 WIN COMMENTS: r�1_.�-��.. IW!� BILLING A,CKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spect -ILENVIRONMENTAL HGAI;1'Ii Di.;PAKTML:N'i' hourly charges associated with this project or activity will be billed to me or my b ness as i ratified on thys.totm. I also certify that I have prepared COUNTY Ordinance Codes, Stand be performed will be done in accordance with all SAN JOAQUIN APPLICANT'S SIGNATURE: PROI'I'JtTY / 13 USI NFSS OWN 1,1113 PF11 TOR / r .lila ❑ THFn Au'rnoitl/..EA AGFNT341 1 f iIPPLiCAN't' is not the i3/l l Lvc 11;I m proof of authorization to sign is required Tfrl e AUTHORIZATION M 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 re-SURS, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN'I'At, HEAi,'ni DEPARTML'N'r as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: RE T COMMENTS: NOV 2 5 2008 SAN JOAQUIN COUNTY ENVIRONMENTHEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P t E: Fee Amount: �� ro Amount Paid `3S, Payment ate Payment Type Invoice # Check # L4 6 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003