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SAN JOAQUIN&LINTY ENVIRONMENTAL HEALT*PARTMENT SERVICE REQUEST Type of usiness Poperty FACILITY ID # SERVICE REQUEST ''# PHONE ) _ EXT. 33 HOME or MAILING ADDRESS OWNE / OPERATOR CHECK If BILLING ADDRESS CITY STATE �/ zip FACILITY NAME La DATE: SITE ADDRESS I I 4 � ,/ � SERVICE CODE: �� Fee Amount: S w 9`�, �//� �iC/CoYde r WF 6. Payment Type S rr t eeYN1a Check # 41 L HOME or MAILING ADDRES (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#'I EXT. APN # LAND USE APPLICATION # 3+- 3a33 PHONE#2 EXT. BOS DISTRICT LOCATION CODE n /J , CONTRdTOR /SERVICE REQUESTOR REQUESTO m ��%/�� U� / CHECK If BILLING ADDRESS BUSINESS A E / I PHONE ) _ EXT. 33 HOME or MAILING ADDRESS F DATE: 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 busi as identified on this form. I also certify that I have prepared thi application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar s, 'GATE and FEDERAL la X 2 - CO? SIGNATURE: DATE: / PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ( ?u " If APPLICANT is not the BILLING PARTY, proof of authorization to sign is regnirTi Ile 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: F0 Amp I COMMENTS: RECEIVED MAY 19 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: / EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already Com leted): SERVICE CODE: PIE: 2� Fee Amount: S w Amount Paid 4,31 S` C Payment Date s �� ID Payment Type Invoice # Check # 41 L Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003