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jC2 4 o Type of Business or Property TYPE OF SERVICE REQUESTED: t FACILITY ID # SERVICE REQUEST # D ACCEPTED BY: EMPLOYEE #: DATE: OWN / P T R EMPLOYEE #: CHECK If BBILLING ADDRESS ll FACIuTYNAME P IE: IT DD . Payment Date S1881 I Invoice # Check # Stre t ber OU1.t HOME or MAILING ADDRESS (if IN rent from Site Addr ) St eel Number S eet Nem CITY ��e� (i 8 r. v STATE ZIP PHONEt ExT' APN # AND USE APPLICATION # [SOS PHONE 02 EXT. DISTRICT LOCATION CODE a s "A 1141111 ill A'i 0911r#a BIL GAC E T: I, the rsigned property or business owner, operator or auraortzea agea7ii—,mow, acknowledge that all site and/or project cific E ONMENTAL HEALTH DEPARTN mNT hourly charges associated with this project or activity will be billed to me o b siness as i ntifled on this form. I also certify that I have prepared ihi p 'catio at the wo o be performed will be done in acco dance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar , STA a EDERAL laws. APPLICANT'S SIGNATURE: DATE' PROPERTY / BUSINESS OWNER❑ OPERA / MANAGER ❑ OTHER AUTHORIZED AGEN If APPLICANT is not the BILLING PARTY. proof Of authoriZadOn 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 esentative provided to me or my I.F. TYPE OF SERVICE REQUESTED: t e _ / ADDRES 0119km "'W_ 1XII ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: pr MAILING r t - 7 O Date Service Completed (if already completed): P IE: Fee Amount: BIL GAC E T: I, the rsigned property or business owner, operator or auraortzea agea7ii—,mow, acknowledge that all site and/or project cific E ONMENTAL HEALTH DEPARTN mNT hourly charges associated with this project or activity will be billed to me o b siness as i ntifled on this form. I also certify that I have prepared ihi p 'catio at the wo o be performed will be done in acco dance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar , STA a EDERAL laws. APPLICANT'S SIGNATURE: DATE' PROPERTY / BUSINESS OWNER❑ OPERA / MANAGER ❑ OTHER AUTHORIZED AGEN If APPLICANT is not the BILLING PARTY. proof Of authoriZadOn 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 esentative provided to me or my I.F. TYPE OF SERVICE REQUESTED: t COMMENTS: Ll'lt—A cQ ! L� _ ` Q ` A Dn/DoL .. `SO ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P IE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) f