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E El v SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR CHEcx if BILWNg ADDRM11 FACILITY NAME SITE ADDRESS §lMlt NameClt&2 CITY C902 HOME or MAILING ADDRESS (if Different from Site Address) Street Number tree CITY STATE zip PHONE #1Exr•APN # LAND USE APPLICATION III PHONE#2 EXT. Fee Amount: BOS DISTRICT � -7 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR I REQUESTOR - --- Crisp -- CHECK if JILLING ADDREJ§ BuSINEss NAME _7-ri 11111; re". r r - 11 IN� CITY STATE C zip _ p 9 BILLING ACKNOWLEDGE VIFNT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMEN-I'At. HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this fon-n. 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, STATE anO FFDr-RAI- laws. APPLICANT'S SIGNATURE: DATE: /J AT THEIR AUTHORIZED Op 00 15UO ORIZEDAGENTP t� V fi, i 0 f 11toriZallon to S 5f4 uthorization to sign is required Title PROPFRTY/ BUSINESS OWNERO 1J'A PPI.K'A,%'T is not the B11J.1.VG PJ!ryr� 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 AL HFALT[J DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: 1.0 ACCEPTED BY: EMPLOYEE DATE: ASSIGNED TO: EMPLOYEE DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: of Fee Amount: Amount Paid Payment Date Payment Type Invoice Check # I Received By: END 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 I