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SAN JOAQUIN -OUNTY ENVIRONMENTAL HEALTF DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# ' Sh c) SF's-maca y� OWNER/OPERATORn //,,—'1 � �r^ I CHECK If BILLING ADDRESS FACILITY NAME � "�I� 1 SITE ADDRESS Street Number DirectionE Street Name EC —: i ZiP Code HOME or MAILING ADDRESS (If Different from Site Address) ' I I l C 1` ' { , Street Number Street Name CITY STATE ZIP PHONE#t EXT. APN# LAND USE APPLICATION# ( ') O M PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME U PHONE# EXT. ( HOME or MAILING ADDRESS FAX# r ( ) 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 forrn. 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 Ia/WS. APPLICANT'S SIGNATURE: L 1\ DATE: PROPERTY/BUSINESS OYVIYER❑ OPERATOR/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. p TYPE OF SERVICE REQUESTED: �1 ,� G�` FC6V COMMENTS: a (.I7I (;1 EAG1,/ `C.� J",7-- OCT 3 0 2001 SAN�OAQUIN COUNTY HIEN 11 DEPMEr ARTWN ACCEPTED BY: CL EMPLOYEE#: 2— DATE: 1(� 3 O lJ ASSIGNED TO: EMPLOYEE DATE: 31/ O' Date Service Completed (if already completed): SERVICE CODE: v ( P/E: Fee Amount: b'„ 00 Amount Paid Payment Date `-3 3 D 0 Payment Type Invoice# Check# 1 O `o Received By:ve, EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003