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SAN JOAQUI0OUNTY ENVIRONMENTAL HEALTVEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADORES FACILITY ID # 1'-A YMENT RECEIVED DEC 2 8 2007 SAEN �RONME OVN1Y IAI SERVICE REQUEST # f TV0g7. / Z Z 6 � goo -=0 Seo 53�z1 OWNER / OPERATOR � FAX # CHECK If BILLING ADDRESS FACILITY NAME _ ( � / a. 0C{�- L `�r� CITY mk"�" SITE ADDRESS �sa — FL)cLier&o te do Payment Type ( I►iT�/ Street NumberFirection Street Name Ci Zlo Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP s PHONE #1 EXT. (a�)V63 APN # /. 2S/� LAND USE APPLICATION # OEXT. BOS DISTRICT LOCATION CODE / CONTRACTOR / SERVICE REQUESTOR REQUESTOR �19Lv CHECK If BILLING ADORES BUSINESS NAME 1'-A YMENT RECEIVED DEC 2 8 2007 SAEN �RONME OVN1Y IAI PHONE# ExT. -6,337 EMPLOYEE #: /�i C TV0g7. / Z Z 6 ASSIGNED TO: HOME or MAILING' KESS - DATE: FAX # � SERVICE CODE: 14��/ 1` 63 CITY mk"�" STATEn - ZIP fn 7/1G — Payment Date l �7,01 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT &y"', `� .. If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: 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: COMMENTS: 1'-A YMENT RECEIVED DEC 2 8 2007 SAEN �RONME OVN1Y IAI ACCEPTED BY: EMPLOYEE #: /�i C TV0g7. / Z Z 6 ASSIGNED TO: EMPLOYEE #: �� DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: 15 Fee Amount:2 Amount Paid — Payment Date l �7,01 Payment Type Invoice # Check # a Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003