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' '--��-s-• 1-1AA Li\V1`TJL 1\ 1HL 11L'HL I U".EYAK I IVIENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Qk(A-0 C� �` 'rl �� a 6 a 3$3 90s_1 Coif' OWNER /OPERATOR CHECK If BILLING ADDRESS FACILITY NAME SITE AbDRESS f �V Street Number Direction Street Name l Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # PHONE #2 ExT. __JBOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUEST I V11 9 CHECK if BILLING ADDRES BUSINESS NAME P N HOME Or MAILING ADDRESS ( CITY -tom e� STATEC— 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 la s. APPLICANT'S SIGNATURE: DATE: PROPERTY BUSINESS OWNER❑ OPERATOR/ MANAGER 0. HER AUTHORIZED AGENT _ - -- If APPLICANT is not theBHJ"GPARTY proof of authorization to sign is require 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 70AQUIN 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: PAYMENT --- - RECEIVED . JAN - 6 2010 SAN JOAQUIN COUNTY ENVI HEALTH D DEPARTMENT NMENTAL ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED T0: EMPLOYEE #: DATE: - Date Service Completed (if already Completed): SERVICE CODE: P VByr: Fee Amount: Amount Paid — Payment Date/_ Payment Type Invoice # �lCheck # M7!GI' Received EHD 48-02-025 REVISED 1111712003 Sf ) Of�IV1(GAold@n'(2od}