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SAN JOA* COUNTY ENVIRONMENTAL HEALODEPARTNIENT SERVICE REQUEST _ Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER/ OPERATOR``tr 400 O CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS %e /�,�j'(,� //''�� Street Number ection 4 ' I l nO p',� q Street Name CI HOME or MAILING ADDRESS -(If Different from Site Address) CITY Street Name STATE ZIP PHONE #1 E,. APN # =LANDUSECATION # PHONE #2 Exr. " r_ BOS DISTRICT LOCATION CODE REQUESTOR CONTRACTOR / SERVICE REQUESTOR ----- ------ fr civ CHECK ifBICCING ADDRESS BUSINESS NAME • .__ _ -- -- - — -'PHONE ^ ` G6{f�l1 HOME or MAILING ADDRES ( ) I FAX #, rn) r CITY (� _ 1lJi 1 STATE A k -N ZIP r1y_— n BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONmF_NTALHEALTH 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 this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, A and FED laws. APPLICANT'S SIGNATURE: / ,,\\ DATE: U PROPERTY /BUSINESS OWNER ❑ . OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY proof of authorization to sign is required t• x Tttt , AUTHORIZATION TO RELEASE INFO tMATION: 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:. PAY COMMENTS: Q ;. R (I Q JUL -- S ZOtO SAN MAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: 1 1Q J� EMPLOYEE 7 (f, DATE: C� D d ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE:' PIE: -.3O Fee Am unP 14 I Amount Paid s Payment Date PaygenWype invoice # Check # l!t �\ Received By: EHD 48-02-025 REVISED 11/17/2003 a a� s -elt"R ,".