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11! U41 cuu•+ U7. JL 4U74001343J rlr IN rLUUN NAUE 02 <br />SAN JOA.QUINC* 1NTX ENYIR0NMEN-TAL HEALTH A�A>ftTMENT <br />SERVICE REQUEST <br />CONTRACTOR t SERVICE REQUE,�'>t'uK <br />i?EQUESTt�R �/' CF/PCK If BIWMG AppRessO <br />BUSINESS NAME � PM4NE# Exr. <br />GC — `f � � N � q2� �S — u6c) <br />HOME or iV1AlUNG ADDRESS S" qZ 5 S S 1 — G v <br />STATE zip <br />CITY D J \ Q <br />BILLING ACKNOWLEDGEMENT: x, the undersigned property or business owner, operator or authorized ,agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL H>-ALTH DEPARTMEmr hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this form <br />I also certify that I have prepared this application and the work to b perfonrued will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Cortes, Standards, STATE an FE 'T� <br />C <br />' �/� ! <br />APPLICANT'S SIGNATURE: DAVE: <br />PROPERTY 1 BUSINESS, OWNER ❑ OPERATO ! MA"" tt C] OTHER AUTHORizim AGER i`� � � (� �� <br />1} APPcrCANT IS /!vr the B11-LlNG PARry proof a f authorizaUion to sign is required Title <br />UTHORIZAT'ION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/site assessment <br />information to the SAN JOAQUIN COVNTY ENVIRONMENTAL HEas soon as it is available and at the same time it is <br />ALTH IDEPAARTMENT <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:91-rn �,T TU <br />Coe�ulExrs: w -'. LEqJN0� <br />SAN /0 52004 <br />"-/VV/,,?AQUI <br />HiD l v F' ou 1.Y <br />ACCEPTED BY: EMPLOYEE #: C j -z i DATE: ! / S rr <br />ASSIGNED Yo: S f{ I EAAPLOYEE #: �3 DATE: <br />-4 <br />Date Service Completed (If already completed): SEtmCE CODE: P 1 E: 3 63 <br />Fee, Amaunt• 7 c % Amount paid a'?q -- Payment Date <br />Payment Type Invoice # Check # Ikecelved By: <br />SR FORM (Golden <br />EHD 46-02=025 <br />REVISED 71/17/2003 <br />