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SAN JOAQUOCOUNTY ENVIRONMENTAL HEALT PARTMENT Type of Business or Property ID # FACILITY ID PHONE # EXT. SERVICE REQUEST # , ! y, 1" � w vel l'I '"��0 l ASSIGNED TO: EMPLOYEE #: OWNER] OPERATOR Date Service Completed (If already completed): CHECK if BILLING 'i I I® ,, i� '�.•�1 4� P I E: ADDRESS❑ F lure ME SITE ADDRESS GO;)- Payment Date Payment Type Invoice # Check # Received By: Street Number Direction treat ame Cit — Zi Code HOME orADDRESS (If Different from Site Address) ^�MAIILING 1-1 ,;L0 ' `° � Street Number Street Name CITY STATE ZIP[ / w PHONE #1 EXT. PN # LAND USE APPLICATION # PHONE #2 EXT• ( ) BOS DISTRICT LOCATION CODE REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS FAx # CITY STATE ZIP 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 I APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPFM(ATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 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: 4Jl 1Skm _ kV0 FW411 or(( �i1 wS 11� ,t FJ WA I Cl � ,Ir x, . (vl i� arta %J`I ti+/lQ,, �j' l U C U 2-01't5.5 DYQ_1`<i' lav ,. i lnc� OISS C;t( l?t IM, o tit 3R - 052.o L 36A CAOSM S"V63 39 ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003