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SAN JOAQUSFOUNTY ENVIRONMENTAL HEALTIOPARTMENT SERVICE REQUEST Type of Business or Property r ADDRESS If BILLING iG:1 FACILITY ID # COMMENTS: SERVICE REQUEST # % li � 2 t� HOME Or MAILING ADDRESS :SERVICE OWNER/ OPERATOR�T RECEIVED CHECK If BILLING AOORE55� CITY t Q FACILITY NAME rl/ SAN JOAQUIN COUNTY r/y SITE ADDRESS J 1 77 �r ,4 ck ACCEPTED BY: O L- t vE t !J-7 to Street Street Number Dlrecdon DATE. StreetN ma • �0 /V � rO' Lt CI i Cade HOME Or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: 03 P(1 E: -;Z 3 Fee Amount:035 O Street Number Payment Date Stree Najma CITY Invoice # Check # S ♦ O h Received By: STATE ZIP PHO\\N,fE#1 Ext. APN # LAND USE APPLICATION tr PHONE #2 En. SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOURSTOR REQUESTOR r ADDRESS If BILLING iG:1 COMMENTS: BUSINESS NAME� 8 Q /yLd� j Col✓ CL (O PHOIIIt:J # ExT S -??— HOME Or MAILING ADDRESS \N FAX# RECEIVED Va (;- CITY t STATE J zip b 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 I Is p cation and t t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Or Codes, Staniar;, ATE and E L laws. APPLICANT'S SIGNATURE: ` DATE* -e PROPERTY/ BUSINESS OWNER❑ OPERATOR/ ANAGER❑ OTHER AUTHORIZED AGENT CJ '�hjp h IfAPPLICANT is not the BILLING PARTY proof of authorization t0 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: U� ] T-%/�'(O COMMENTS: PAYMEM RECEIVED OCT 0 5 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL TH ARTTMENT ACCEPTED BY: O L- t vE t EMPLOYEE M D_g 2;Z DATE. ASSIGNED TO: • �0 /V � rO' Lt EMPLOYEE Zle�70 DATE: Date Service Completed (if already completed): SERVICE CODE: 03 P(1 E: -;Z 3 Fee Amount:035 O Amount Paid I D3 S O Payment Date Payment Type ✓ Invoice # Check # S Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 1111712003 _