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• 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'r SERVICE REQUEST r ype of B siness o rop CHECK if BILLING ADDRESS FACILITY ID # -'9-0C200 5-110 COMMENTS: SERVICE REQUEST # OWNE OPERAT R C CHECK if BILLING ADDRESS El FACILITY NAME STATE ZIP a-7- /it3— SAN JOAQUIN COUNTY SITE ADDRESS 4SetNum Direction Street Name CJC%-•C" }IEALTH DEPARTMENT Zip Code HOME or M I AD ESS (If Different from Site Address) °yf L Street Number /' 14tV qtreetlaame CITY DATE: STATE OA PHONE #1� EXT. PIE: U APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. j / 8 BOS DISTRICT Invoice # LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: PHO, EXT. l_ 3 HOME or MAILING ADDRESS ^�r ' "' FAX# 1 �n Z12 �CIIL� CITY nh STATE ZIP a-7- /it3— BILLING ACKNbW EDGEMENT: 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 p lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar , S ATE and FED s APPLICANT'S SIGNATURE: / DATE: I� PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT 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. TYPE OF SERVICE REQUESTED: IV V ED COMMENTS: NOV 12 2004 SAN JOAQUIN COUNTY ENVIRONMENTAL }IEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: MPLOYEE #: DATE: Date Service Com leted (if already completed): SERVICE CODE: PIE: U Fee Amount: Amount Pai �`7 y1 Paymentate j / 8 Payment Type Invoice # Check #�' Received y:tv EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)