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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTWEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRES. FACILITY ID # SERVICE REQUEST # ACCEPTED BY: Q LA uE f >-04 PHONE # EXT' OWNER/ OPERATOR DATE: -7 Q CHECK If BILLING ADDRESS C41 STATE ZIP /� CJ FACILITY NAME Date Service Completed (if already completed): SITE ADDRESS SERVICE CODE: (9e- �treatl F. Fee Amount: -131 S U-0 Amount Paid J �� Street Number DlrectI. 3� ame✓� city Zip Cod HOME or MAILING ADDRESS (If Different from Site Address) R ceiv By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # W2) 5 ,f?- 9.x 71 if , 0 '),0 /f PHONE R ExT• BOS DISTRICT LOCATION C DE CONTRACTOR / SERVICE REQUESTOR REQUESTOR rir C' / �� !J CHECK If BILLING ADDRES. BUSINESS NAME / // ` s� :-� / / ACCEPTED BY: Q LA uE f >-04 PHONE # EXT' HOME or MAILING ADDRESS DATE: -7 Q FAX # CITY �V STATE ZIP /� CJ 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. 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, ST E and FEDERAL laws. J APPLICANT'S SIGNATURE: DATES:( O 1 / is T PROPERTY / BUSINESS OWNER❑ PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT If APPLicawT is not the BILLING PARTY, proof of authorization to sign is required Title 14) AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the prope 4 ed at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environme U' ` dent Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and � , rn nt is provided to me or my representative. S�� 30 TYPE OF SERVICE REQUESTED: U SI1 R E tRo F / T -- E V R u f 6ILA-! 611-0 � 9 COMMENTS: A f%PLI (Zi T D (JP �R-t¢DE Sys M w l�� V l��D/� s -X -r f to No(a�'y 10HAS� ,,'! witH vEEAdA —RaO't C &N I ti✓/� WOQ Potgs#EA N a (is D) 1A) -5447h aAJ - pi,q cgws l c -s �x£'C tic Oxoea' VIQ—.2'z3-F ACCEPTED BY: Q LA uE f >-04 EMPLOYEE #: (29 3-Z DATE: -7 Q ASSIGNED TO: EMPLOYEE #: c?,&3 > _ IC/ DATE: Date Service Completed (if already completed): SERVICE CODE: (9e- P : F. Fee Amount: -131 S U-0 Amount Paid J`. -- Payment Date 3� Payment Type V Invoice # Check #P.-2 S6 / R ceiv By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003