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SAN JOAQUIN COUNTY F.NVIRONMFNTAL HPAUrH DFPARTMEINI, <br />SERVICE REQUEST <br />T pe of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST <br />I?- C C) <br />S— <br />Date Service Completed (if already completed): SERVICE CODE: P I E; <br />WNER / OPERATOR <br />FAX <br />(-U,") <br />3 <br />CHECK if BILLING ADDRESS <br />STATE <br />zip �pz- 61 <br />FACILITY NAME <br />C 0 0-y <br />SITE ADDRESS <br />(:/Streot <br />I�K 2 <br />/6-/7 Stri <br />ion <br />Name <br />ZiD Code <br />ROME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE 7ip <br />PHONE #1 <br />APN # <br />LANE) USE APPLICATION <br />PHONE #2 Ex'r. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE(, UESTOR <br />REQUESTOP/,? <br />-z- <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />CHECK if BILLING ADDRESS <br />BUSINESS 4ANTE <br />PHONE# <br />Date Service Completed (if already completed): SERVICE CODE: P I E; <br />HomE or MAIUNG ADDRESS <br />FAX <br />(-U,") <br />3 <br />-///C? <br />CITY <br />STATE <br />zip �pz- 61 <br />BIL!JNG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same. <br />acknowledge that all site and/or project specific rNVIR0NMI-.XI*AI. HFAIJI I DEPARTMENT hourly charges associpted with this project <br />or activity will be billed to me or any 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 JOAOuIN <br />('01 INTY 01-dineince (,toys, Slawlar(is, STA,rF and FEDFRA 1, laws. <br />- <br />APPI,x(,'ANT'S SIGNATURE: DATE: c ( <br />OPERATOR/MANAGI'.. 0 <br />PROPER*: Vr BUSINESS OWNER r-1 <br />",tv'l, is not the nli.rmtc; 1x,.ym proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby aLItlIOFiZC the release of any and all results, geotechnical data and/or environincrItal/site assessment <br />in!'ormation to the SAN JOAQUIN ('0UNTY ENVIRONMIXI'Al, FIEAL'I'li Di-A'ARTMENTaS 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 />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: <br />EMPLOYEE <br />Date Service Completed (if already completed): SERVICE CODE: P I E; <br />Fee Amount: Amount Paid 7Payment <br />Date <br />Payment Type Invoice # <br />Check # —T— <br />Received By: <br />FHD 48-02-025 SR FORM, (Golden Rod) <br />REVISFr) 111/1712003 <br />