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SAN JOAQUOVOUNTY ENVIRONMENTAL HEAI0DEPARTMENT SERVICE REQUEST Type of Businessh Property CHECK if BILLING ADDRESS BUSINESS NAME WI TX u / Vfu LJ FACILITY ID # PHO-yNE# EXT. 533 IC(C I - C�i�✓ SERVICE REQUEST # I FAX # CITY /! Ill �_�ooc� �-j �' (� OWN /OPERATOR T Y �/ I(C�,,I ^ � ENVIRONMENTAL CHECK if BILLING ADDRESS FACILITY NAME aim - f fl 60 EMPLOYEE #: ~ L DATE: c l ASSIGNED TO: SITE ADDRESS, EMPLOYEE #: DATE: &S'treetNaffij SERVICE CODE: PIE: Number Direction � QStreet Fee Amount: Zip Code HOME Or MAILING A DRESS (If Different from Site Address) `7 ( Payment Date -= i Payment Type DV Street Number Street Name CITY Ui lk � Ip 7 gO g Exr. ApN # LAND USE APPLICATION # PHONE #2 Ex BOS DISTRICT LOCATION CODE +C /11-1 CONTRACTOR / SERVICE REQUESTOR REQUESTO bill i '" CHECK if BILLING ADDRESS BUSINESS NAME WI TX u / Vfu LJ COMMENTS: PHO-yNE# EXT. 533 IC(C I - C�i�✓ HOME Or MAILING ADDRESS � FAX # CITY /! Ill ^ C� STATE BILLING ACKNOWI,EDGF.MENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-I 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 t is pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stand rds, SThC�and FEDERAL laws. APPLICANT'S SIGNATURE: I DATE- 10 l`u PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGFNT - �V If APPLICIINT is not the BILLING PARTY, proof ojaathorization 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 informatioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. If TYPE OF SERVICE REQUESTED: (� S�11 -A- I COMMENTS: I PAYMENT RECEIVED OCT 2 9 2003 SAN JOAQUIN COUNTY ENVIRONMENTAL APPROVED BY: EMPLOYEE #: ~ L DATE: c l ASSIGNED TO: C > ` EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid `7 ( Payment Date -= i Payment Type Invoice # Check # Received By: EHD 48-01-025 SERVICE REQUEST FOR REVISED 6-5-02 011