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SAN JOAQU0OUNTY ENVIRONMENTAL HEALTHOARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS BUSINESS NAME FACILITY ID # PHONE# ExT' HOME Or MAILING ADDRESS SERVICE REQUEST # FAX# — CITY STATE Z.ZIP 00 C)3 ENVIRONMENTAL .S/ o OWNER / OPERATOR ACCEPTED BY:!st �! EMPLOYEE #: 2'Aw CHECK if BILLING ADDRESS —" EMPLOYEE #: /S.f DATE: Date Service Completed (if already completed): FACILITY NAME SERVICE CODE: P 1 E: 70L Fee Amount: L . Payment Date V Payment Type ✓ Invoice # SITE ADDRESS �i /10 Street Number Direction Street Name citv 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 # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR JAS W CHECK If BILLING ADDRESS BUSINESS NAME COMMENTS: PHONE# ExT' HOME Or MAILING ADDRESS FAX# — CITY STATE Z.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. 7 / APPLICANT'S SIGNATURE: DATE: PROPERTY /BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �aexlf � a�h " 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. TYPE OF SERVICE REQUESTED: PAY ME COMMENTS: JUL 16 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY:!st �! EMPLOYEE #: 2'Aw DATE: ASSIGNED TO: EMPLOYEE #: /S.f DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: 70L Fee Amount: Amount Paid5 . Payment Date V Payment Type ✓ Invoice # Check # aaq 1 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003