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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Ty of Busi ss or Property I Q FACILITY ID # PHONE# EXT. (2.6g) -'+Co I - & 5l SERVICE REQUEST # t(il(- ' r, 6� EMPLOYEE #: �3 OWNER/ OPERATOR ASSIGNED TO: t CHECK If BILLING ADDRESS f^ DATE: Date Service Completed (if already completed): SERVICE CODE: / P ! E: Fee Amount: Z Amount Paid FACILITY NAME /% I t �v-�-n �c� %%t�..�v CenT � Car , 1 W Invoice # SITE ADDRESS 3;I3q E tIt� rh-AAI �k,�� Street Number Direction street Name city Ci Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) AMEStreet Number Street Name CITY STATE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # (aM )iso - �a t(t) PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS Q BUSINESS NAME 1 ` -a n C�C,�" PHONE# EXT. (2.6g) -'+Co I - & 5l HOME or MAILING ADDRESS 6 FAX # (2(Y7) 4Co CITY 1b STATE ZIP CIC 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/ ATE and FEDERAL laws. APPLICANT'S SIGNATURE: hvv—L, A1WDATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT IfAPPLICANT 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. ,,/ I\ h F N -T TYPE OF SERVICE REQUESTED: RECEIVED COMMENTS: �p (�t `a 1 on Fat t l � nv MAY 2 3 2008 SAN JOAC)OIN COUNTY ENVIRONMENTAL ��ETI-{ DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: t EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: / P ! E: Fee Amount: Z Amount Paid �q O Payment Date Payment Type (/ Invoice # Check # 1-;L I D Received By: EHD 48-02-025 ,SR FORM (Golden'Rod) REVISED 11/17/2003