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BILLING ACKNOWLEDGEMENT: I, 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:1 • fAjl<1 /4.-....._ DATE: AS- - 7) — Z 0 1 -7 <br />, <br />vyKet <br />PROPERTY / BUSINESS OWNER El OPERA / ANAGER 0 OTHER AUTHORIZED AGENT.51 s)' FL 'TNtiCtr if - <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When 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 />SAN JOAQU... COUNTY ENVIRONMENTAL HEALTt. _,EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />EL- Oc.za P 0 I- An ID 1-4.1 Li- - (-- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME __,...,<- AL 1 C.)12/N I A) <br />/AN K L 1 'It 5 -I n ( . .-11f2 <br />SITE ADDRESS 4 i , c <br />.., 1 ‘...) ..." <br />Street Number <br />5 <br />Direction <br />r L.- 0 c.. A " p c, si-- . <br />Street Name <br />S ro c IC T() ,,,/ <br />City <br />9' 5-R \io <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR — <br />/jet TL 3 C--.3 Z i 1 A ."--• 0 7 CHECK if BILLING ADDRESS N <br />BUSINESS NAME PHONE <br />4banc.: k:40 a, EA' „,,,,,,,„..„k,„-i-A) -Inc_ , <br /># <br />(2S) 4001- <br />Err. <br />HOME Or MAILING ADDRESS <br />33( <br />Fax # <br /> zk, ) 40- Ill <br />CITY 5 TQC, K -1- o././ igf- STATE (._ 6 ZIP 9 5 15 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: PIE: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003