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. "JAN -30-2006 MON 05:14 PM FAX N0, P. 02 <br />SAN JOAQU OUNTY ENVIRONMENTAL HEALTH Y, ,PARTMENT <br />SERVICE REQUEST <br />BUSINEss NAmr: <br />�[ 2:zu ty <br />Fi0- ME01 Al��Sii <br />Crry <br />CH=Kif LLiNGADDRESS❑ <br />EXT. <br />FAX # <br />1 ( !O 1) IM - <br />STATE Zip <br />BILLING AMM&DGEMENT: I, the undersigned property or business owner, operator or an><normeo f gcnv or a,m"r., <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTM# NT hourly charges associated with this project <br />or activity will be billed to sue or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATS and FEDERAL laws. <br />APPLICANT'S SIGNATU . DArE— <br />Aj <br />PROPERTY / BVstN1EeS OW OPERATOR / R ❑ OTHER AvTHowzrp AGaNT <br />If APPLICANT is not the &Q G P R propf of authorization to sign is required rarYe <br />AUTFIORIZATION TO RELEASE INPORMATTON: When applicable, I, the owner or operator of the proper r located at the <br />above site address, heraby authorize the release of any and all results, geotechnical data and/or environmentalh ite assessment <br />information to the SAN 7OAQu N COUNTY ENviRoNMENTAL HEALTH DEpAkTmENT as soon as it is available antime it is <br />provided to me or my representative. fit `�v�F�E� <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />n <br />�►`� cOVN``( <br />SAN �� PNM RjM�N� <br />H LTN MEPP <br />ACCEPTED BY: <br />F-MPLOYEE <br />DATE: a7 <br />AssIGNED T0: <br />EMPI.QYrz 3 <br />WE: d <br />Ditto Service Completed (it already completed): <br />SERVICE CODE:: <br />PIE: <br />Fee Amount; c! -v Amount Paid <br />Payment Date <br />t/3 O Oto <br />Payment Type <br />Invoice # <br />Check # Z `7(, <br />Received B;Ir. <br />E:HD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />