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SAN JO4IN COUNTY ENVIRONMENTAL HEAL*EPARTMENT . SERVICE REQUEST CHECK BUSINESS ExT. HOME or MAILING ADDRESS ��j f F�Ax#W J (—&3 /_ QP CITY 0 Y41A Y,-J4�n J f1l, STATE ZIP ('I = -nnG 13ULING 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, nTE and FEDERAL laws. // APPLICANT'S SIGNATURE: l� DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTYY, proof of authorization to sign is require Tine 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: .S e2-6-r�l f (-I- PAY RE-GEIVED COMMENTS: JUL - 8 Nil SAN JOAQUIN COUNTY ENTAL H�TM DEPARTMENT ACCEPTED BY: •, C ` t l/ EMPLOYEE #:S Z DATE: 7 f! ASSIGNED TO: C _ y/ �� EMPLOYEE #: L/ Z 2_ DATE: Date Service Completed (if already completed): SERVICE CODE: Ct �; PIE: Z34 Fee Amount: 3 L`�.I Amount Paid `� 3 �- Payment Date Payment Type UxInvoice # Check # -7 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003