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'• FEB/0.7/2008/THU 05:12 PM Rsign Group FAX No,916 7755 P,005 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTu DEPARTMENT <br />SERVICE REOVEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if JLLDr, &DoREL...1 <br />P NI=1i Exr, <br />BIjS{NE$$ NAME LZ�L �� II,I� ''1 '� <br />HOME or MAILING ADORES 9 t l ~7 1 r� ( # l l <br />1 t (r l�J �j�^� <br />CITY TAC./ �� t I I e ` STATE (^1A z p 1�'�ki <br />$�)(, KNOWLEDGEMENI; 1:, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand a STA E and FJEDEL laws. <br />APPLICANT'S SIGNATURE: DATE: 2, •�� <br />PROPERTY IBUSINESS OVIWNER❑ OPERATOR/MR OTHERAUTaom. ED AGENT <br />IfAPPLICANT is not the BILLINCr P�Ixof o authorization to sign is required rifle <br />AUTHORIZATION RELEASE INFORMATION. hen applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />'TYPE OF SERVICE REQUESTED. P/�,Y M E I�1 T <br />bb 1 � LyCI V <br />COMMENTS: / /B^� '��..s✓�[/ �"_� IJZI�/J� F EB f LOUD <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: H EMPLOYEE##: --J DATE: <br />ASsi(mFo T0: EMPLOYEE##: DATE: <br />Data Service Completed (if already' completed): SERVICE CODE: P 1 E: <br />Fee Amount: C s Amount Paid 1-2 <br />Payment ate <br />Payment Type , Invoice # Check # � 6 3 t L b Received 13' <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />