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Post -If Fax Note 7671 <br />Date <br />pages <br />PHONE# ExT. <br />O� 6 <br />2 - <br />TO <br />To <br />From <br />1r405A a wJ art CIFLTt <br />t, • t.uC�-'- S <br />Co./Dept. <br />Co. S <br />C.4e;f't0 <br />C <br />-r <br />Phone # <br />Phone # <br />'+tit 3f, �z�C <br />4b80 <br />Fax #�G-S tg43 <br />Fax # <br />MENTAL HEALTIOPARTMENT <br />1EQUEST <br />FACILITY ID #`5 SERVICE REQUEST # <br />-7 0�tt C (-I KV <br />CHECK if BILLING ADDRESS 0 <br />FACILITY NAME <br />o 1 ��C� <br />SITE ADDRESSJCS q z,� <br />���/ <br />l[i Street Number �ction Street CI ZipCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #t EXT 7PN # LAND USE APPLICATION # <br />( ) <br />PHONE #2 EXT. BIDS DISTRICT LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTR <br />( CHECK If BILLING ADDRESS <br />, 'b'SCil � A <br />BUSINESS N, <br />PHONE# ExT. <br />,uL <br />HOME Or MAILING ADDRESS <br />FAX # <br />CITY �—o , I ` STATE C..� ZIP 9'5--Z' <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: -Z o U <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />(IV— ID <br />JP -NF - <br />COMMENTS: <br />2 5 2006 <br />,uL <br />SAN JOAQUIN COUNT <br />EAL H DEPA TM T <br />HTAL <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />DATE: <br />ASSIGNED TO: LU GAS <br />EMPLOYEE #: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: —7 <br />Fee Amount:J 7, d' <br />Amount Paid <br />4g-77' OD <br />Paymeift Date —71 n SOi/ <br />Payment Type <br />Invoice # <br />Check # �.� / <br />Received By:v <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />