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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property a1o)o FACILITY ID # SERVICCE� UEST A dt ZQ�J V, 60 (P.�D OWNER / OPERATOR O�p T qZ '7 7— d7n /'n MF'�T CHECK if BILLING ADDRESS .FACIurYNAME I EMPLOYEE#: DATE: 2 GP r (� SITE ADDRESS ' DATE: L Date Service Completed (if already completed): �� ' SERVICE CODE: PIE: %VU Se,e tuber D -1-1V' Amount aid -0/'5C/ v Z) Y SGe a `� - Payment Type -;4K J Invoice # H ME Or MAILING ADDRES[S� (If Different from Site Address) Received By 0 �1 Street Num er Street Name CITY STATE G PHONE#1 LAND USE APPLICATION# `HONE#$r(Ijl gaa1 1q 1 ExT, BOS DISTRICT LOCATON CODE / CONTRACTOR / SERVICE REOUESTOR REQUESTOR BUSINESS NAME ME Of MAILING All ne CITY f BILLING ACKNC acknowledge that activity will be billed IWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ill site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with -this project or 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 and FEDERAL laws. / APPLICANTS SIGNATURE C- �� - DATE: 6 0 Z PROPERTY/ BUSINESS OWNERA1- OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is\bot the BluiNG PARTY. proof of authorization to sign is required - title 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 HEALTH DEPARTMENT as soon as it IS available and at the same time it is pro to me or my representative. OF SERVICE REQUESTED: a1o)o eLicn �TYPE � COMMENTS: VroorvV n ZQ�J yE cM9Ro �O yc O�p T qZ MF'�T ACCEPTED BY: r ✓1 I ' EMPLOYEE#: DATE: 2 ASSIGNED TO: Ib l EMPLOYEE#: DATE: L Date Service Completed (if already completed): I SERVICE CODE: PIE: Fee Amount: 13 1 . UO Amount aid -0/'5C/ v Z) Payment Date 4Pjy/ Payment Type -;4K J Invoice # Check # Received By EHD 48-02-025 07/17/08 SR FORM (Golden Rod)