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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property r FACILITY ID # PHONE# EXT. ( SERVICE REQUEST # FAX # 0 0 �./ Z�L OWNER/ OPERATOR CHECK If BILLING ADDRESS =r,, '� 11 � yy/ /� _ K SAN JOAQUIN COUNTY FACILITY NAME ilfir / rKb �(�� L ruC, SITEADDRESS 1�L (�U��('� CQ �fVf �`(�CKTbN n� Street Number Direction Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: Street Number DATE: Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # (2U15) � C'l - 065A SERVICE CODE: P 1 E:Alf PHONE#2 ExT• BOS DISTRICT 11 LOCATION CODE ( e ) M6 - 7S-7/ Payment Date Payment Type CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. ( HOME or MAILING ADDRESS FAX # 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 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:'jt'T S� DATE: - 7� PROPERTY/ BUSINESS OWNER El 0"/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLiNGPARTY , 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. TYPE OF SERVICE REQUESTED: S PAYM E 1 COMMENTS: /�,� • / Ow. �. ,�//�y\/ JAN 2 2 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #:2J f DATE. Date Service Completed (if already competed): SERVICE CODE: P 1 E:Alf Fee Amount: �8, ' Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 ;S'R FQRM (Golden Rod)