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3AIN J$0 AV WIN I-,VUIN 1 Y L' 1.1 V 1111WINIIVIL' IN IAL, ��4+1L' Al., 1 r1 4/L' /'/l1V 11'11.1 I 1 SERVICE .R.EQUEST • Type of Business or Property FACILITY ID # SERVICE REQUEST # MAY 13 2005 as 'SW Oki f� ��1 � i �'z--oo33,5 DUSINESS NAME OWNER / OPERATOR PHONE EXT. DATE: b ASSIGNED TO: �c�, CHECK If BILLING ADDRESS El FACILITY NAME / y HOME or MAILING ADDRESS Date Service Completed (if already Completed): SITE ADDRESS/QO�� SERVICE CODE: (� P I E:" ilU Zs1 Payment Date 3 Street Number Dlrecllon ZIP � 2— Q treeI Name Check It ty "PC..,],- I CudeHOME HOMEOr MAILING ADDRESS (If Different from Site Address) Street Number Street Narnc CITY STATE zip PHONE #'i I=XT APN # LAND USE APPLICATION # PHONE#2 EXT. t ) BIDS DISTRICT LOCATION CODE CONTRACTOR / SE! RVICE REQUESTOR REQUESTOR MAY 13 2005 COMMENTS: CHECK If BILLING ADDRESS SANNVVIRONMENJOAQUIN OTM ENVIRONMENTAL HEALTH DEPARTMENT DUSINESS NAME ACCEPTED BY: PHONE EXT. DATE: b ASSIGNED TO: �c�, z siz DATE: HOME or MAILING ADDRESS Date Service Completed (if already Completed): FAX It SERVICE CODE: P I E:" (2"0 f ) Zs1 Payment Date 3 CITY STATE /3 n ZIP � 2— Q BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of s true, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENThourly charges associated with this plojcct or activity will be billed to me or my business as identified on this form. I also certily that I have prepared this application and that the work to be performed will be done in accordance with all SAI I.IOi r�ulr: COUNTY Ordinance Cod(..S, Slunclurc/s, STATr and FEDrRAL laws. / APPLICANT'S SIGNATURE: DATE: 1'Ro1'6R'I'Y / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTuLIt AaTnot m'M Acr•.N'r ❑ //*i11111LIC ANT is nol the BILLING PARTY, proof (f authorization to sign is required Title AUTHORIZATION 'I'O RELEASE INFORMATION: When applicable, 1, the owner or operator of tic property located • t the above site address, hereby authorize the release of any and all results, geotechnical data and/or t�, itc asses. mcnt information to the SAN .IOAQUIN COUNTY ENVIRONMENTAL l•IEAL'I'II DrPAR'rMrN'r as soon as it is ttvai1�U11c,altd `Cj� /t�l�! 11TW tim it iS provided to me or my representative. I A t----555S��& v �-�—' TYPE OF SERVICE REQUESTED: MAY 13 2005 COMMENTS: S r� r% SANNVVIRONMENJOAQUIN OTM ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE is DATE: b ASSIGNED TO: �c�, EMPLOYEE : -� DATE: Date Service Completed (if already Completed): SERVICE CODE: P I E:" Fee Amount: Amount Paid l - 0,Q Payment Date 3 rF7,,me7ntType invoice ft Check It Received By: EHD ,18-02-025 REVISED 11117/2003 SR FORM (Grildett Rod)