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SAN JOAQUIIPUNTY ENVIRONMENTAL HEALTfeEPAWYMENT SERVICE RE, 6UEST Type of Business or Property C AAS -k c, � Ld CHECK if BILLING ADDRESS a U FACILITY ID # g OFCo 1 AJ1rut\ C. c� S O- a S 1 HOME or MAILING ADDRESS FAX # OWNER / OPERATOR &a ) (DS CHECK if BILLING ❑ SAN JOAQUIN COUNTY ADDRESS FACILITY NAME A rcc ENVIROMMENTAI HEALTH DIVISION SITE ADDRESS { 1 � r•Y � rn U�..�- { TE: q ASSIGNED TO: ice. IC5 V\'- C\01 cl f K � 6� A Street Number Direction Date Service Completed (if already completed): Street ame Ci Zin Code HOME or MAILING ADDRESS (If Different from Site Address) Fee Amount: 21 Amount Paid LC . Payment Date Street Number Street Name CITY STATE ZIP PHONE #'I ( ) Ex T• APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. 80S DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A ❑ BILLING C AAS -k c, � Ld CHECK if BILLING ADDRESS a U BUSINESS NAME �' S•UJG PHONE # EXT. OFCo 1 AJ1rut\ C. c� S O- a S 1 HOME or MAILING ADDRESS FAX # to-N%."z A'JZN'i'P &a ) (DS CITY SIA E ZIP-Urns- IPVr S 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, STATE FEDERAL laws. q /� APPLICANT'S SIGNATURE: .9- DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 10 AU Q N K— 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: _ PAYMENRECEIVED COMMENTS: SEP 2 4 200: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMMENTAI HEALTH DIVISION APPROVED BY: EMPLOYEE M, TE: q ASSIGNED TO: ice. IC5 V\'- C\01 cl f K � 6� A EMPLOYEE M. 0 3 73 DATE: Date Service Completed (if already completed): SERVICE CODE:VP / E: 13 Fee Amount: 21 Amount Paid LC . Payment Date Payment Type EHD 48-01-025 REVISED 6-5-02 Invoice # Check # Received By: SERVICE REQUEST FORM