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oto J SAN JOAQUI OUNTY ENVIRONMENTAL HEALT EPARTMENT SERVICE REQUEST Typ f Business or Property FACILITY ID # SERVICE REQUEST # clFA OM i55 q 59D0-:5--7 V LIE OWNER/ OP RAT,OR %( FAX# CHECK If BILLING ADDRESS CITY I STATE / ZIP FACILITY NAME r!� ASSIGNED TO: Vb EMPLOYEE #: SITE ADDRESS Date Service Completed (if already completed): ? rct g/ P 1 E: �3 /J lq)�n CJtiStreet /�Zi Number Direction Street Name i T: Code HOME or MAILING ADDRESS (If Different from Site Addres ) Street Number (c me CITYi I STATE hh-� ZIP 01-1 V &Q,�2— PHONE #1 EXT. APN # LAND USE APPLICATION # (J3o) PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR/ LAC CHECK if BILLING ADDRESS BUSINESS NAME PHONE EXT. HOME or MAILING DDRESS - / FAX# CITY I 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 thisa 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards T TE and FEDERAL laws. APPLICANT'S SIGNATURE: (, DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT -B, If APPLICANT is not the BILLING PARTY 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. TYPE OF SERVICE REQUESTED: (t -_C. "-r (Z -e -r" f - I COMMENTS: PAYMENT RECEIVED APR 12004 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: (_ t L (,L! EMPLOYEE #: 3 _ H !,YEPA,F}T O ASSIGNED TO: Vb EMPLOYEE #: (� DATE: Date Service Completed (if already completed): SERVICE CODE: rct g/ P 1 E: �3 Fee Amount: Z� 4l 0 Amount Paid -� q Payment Date { i Payment Type ✓ Invoice # Check # <E�a Received By EI -+D 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)