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.7 SAN =JOAQUI*UNTY ENVIRONMENTAL HEALT0EPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQUESTOR REQUESTOR I Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE# EXT. ( Gas 6L i s P�►-'sr ,� G -FA ') i I J 7 ( 5 CITY i ,h I /� ACCEPTED BY: OWNER / OPERATOR EMPLOYEE #: 3 � C CHECK If BILLING ADDRESS DATE: FACILITY NAME -7 / EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: t SITE ADDRESS3 fi(i I Fee Amount:d7,�� waI. lv© /"aT Payment Date 57(I 2Oq �5� Invoice # Street Number Direction Street Name Ci Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # (53d C-,, D!• PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I C �_'n z r CHECK if BILLING ADDRESS BUSINESS NAME(/ PHONE# EXT. ( HOME Or MAILING ADDRESS—b -7 ') i I J 7 ( 5 CITY i ,h I /� ACCEPTED BY: STATE ZIP � u 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 firm 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, Stand STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: Q/ PROPERTY/ BUSINESS OWNER❑ OPERATOR/ 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.IT TYPE OF SERVICE REQUESTED: RECb\/EC COMMENTS: SAN JOAQUIN COUNT'/ ENVIRONMENTAL HF-ALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: 3 � C DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: t P / E: Fee Amount:d7,�� Amount Paid itf3� �ZL-� 643312 Payment Date 57(I 2Oq Payment Type � Invoice # Check # 113-:? Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003