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------------- _ = _ SAN .JOAN COUNTY ENVIRONMENTALv. S U HEALTH DEPARTMENT °' SERVICE REQUEST Type of Business or Property FACILITY ID # FA SERVICE RREQ/UEST # FA OtV 0 47� S4W WNER / OPE TOR /// lip i � CHECK if BILLING ADDRE. . SIT Fi{, DDRES . f Street Number Direction Fo'�+St�ee a ,, e HOME Or MAILING ADDRESS (if Different from Site A dress) c' ZipcodiE7 Street Number Street Name CITY STATE Zip PHONE #1 Exr. APN # LAND USE APPLICATION # PHONE #2 E.T. ( ) BOS DISTRICT LOCATION CODE REQUEST CONTRACTOR / SERVICE REQUESTOR �` f- -e�4` co \4u CHECK if BILLING ADDRESS ❑ BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS '009) C,) r J-? FAx # CITV ( ) STATE Zip BILLING ACKNOWLEDGEMENT: 1, 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. 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: r �L , DATE: 14� -l6 PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ /f APPLICANT is not the BILLING PARTY proof of authorization to Sign /s required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: U -e,7 - COMMENTS: J ACCEPTED BY: ASSIGNED TO: Date Service Completed (if already completed): Fee Amount -.76 �Amo�tid Payment Type 4/ Invoice CE RECEIVED DC 13 2013 SAN JOAQUIN COUNTY ENVIROMENTAL LrAT EMPLOYEE #: �� DATE:11 % 12 1,3 MPLOYEE #: / DATE: SERVICE CODE:I Cl (/ lDate P / E: �3 o Payment eck # --te- Received y: EHD 48-02-025 07/17/08 SR FORM (Golden Rod)