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SAN JOAQT COUNTY ENVIRONMENTAL HEAL? )EPARTMENT SERVICE REQUEST Type of Business Or Property El FACILITY ID # tib Z- CHECK If BILLING ADDRESS SERVICE REQUEST # �o OWNER / OPERATOR PHONE# EXT' EMPLOYEE#: CHECK If BILLING ADDRESS FACILITY NAME HOME Or MAILING ADDRESS EMPLOYEE #: FAX# SITE ADDRESS IS tI Street Number S, Dlrectian %\t�15 AV �. Street Name I"'�d• city STATE GA ZIP Q$i 9S2 -4Z Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number treet Name CITY Invoice # STATE ZIP PHONE#1 ( ) EXT. APN # LAND USE APPLICATION # PHONE#2 ( ) EXT, BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR El IS CHECK If BILLING ADDRESS BUSINESS NAME RECEIVED JUN - 5 2012 S R.oAoL-w COUNTY =_,-nROnu=_N'AL PHONE# EXT' EMPLOYEE#: DATE:'7 HOME Or MAILING ADDRESS EMPLOYEE #: FAX# DATE:(/ Date Service Completed (if already completed): (1C ) SS CITY STATE GA ZIP Q$i 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: �7 ---�j L C? r t:;- DATE: J&2„C, Pt 2nt't_ rr77 PROPERTY/BUSINESS. OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT gtt hvvk IfAPPLICAAT is not the BILLING PAR TP proof of authorization to sign is required TW e 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 ENvtRONMENTAL 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: RECEIVED JUN - 5 2012 S R.oAoL-w COUNTY =_,-nROnu=_N'AL ACCEPTED BY: L,/ r / EMPLOYEE#: DATE:'7 ASSIGNED TO: �� EMPLOYEE #: DATE:(/ Date Service Completed (if already completed): SERVICE CODE: Z ?� P I E: '760 li Fee Amount: 2.5U '• Amount Paid � A57t � Payment Date Payment Type Invoice # Check # 3Q Recei ed By: C, EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003