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SAN JOAQI! COUNTY ENVIRONMENTAL HEALT4 EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # / CHECK H BILLINo ADDRESS❑ BUSINESS NAM OWN R/OPERATOR EMr• ^�•l r-1gx,2 ACCEPTEDBY: .(,C =EMPLOYEE CHECK If BILLING ADDRESS❑ FACILITY NAME e rim w-, c1 SREADDRES3& Date Service Completed (if already completed): 1`.'f^ Y ' PIE: r'all52i a ``'/Z1. u ber D'recl Payment Dato bee '" Type C Code HOME or MAILING ADDRESS (if Different from Site Address) Street Numher Street Name CITY STATE ZIP PHONE#t Eu. APN # LAND USE APPLICATION # PHDNE#2 FXT• I I BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTO I COMMENTS: CHECK H BILLINo ADDRESS❑ BUSINESS NAM PH E# EMr• ! 1L1H OEMRTME ACCEPTEDBY: .(,C =EMPLOYEE S HOME or MAILING ADDqEks ASSIGNED TO: �,�„L•` FAX# DATE: 2-1 2 Date Service Completed (if already completed): t2GM) PIE: CITY STATE /) a ZIP (JI '� lL� •`� 2— BILLING BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTB 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 prepar application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, ndards, TATE. and &RAL awl APPLICANT'S SIGNAT RE: lDA n 22 TE: PROPERTY I BusmESS OWNER ERATOR/MANAGER❑ OTRERAuTuoalz AGENT❑1,10 IfAPPLfCAm' is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, f, 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 saplpl#101t • provided to me or my representative. RECEIVEn TYPE OF SERVICE REQUESTED: COMMENTS: X)AQUIN COUNI I NVIRONMENTAL ! 1L1H OEMRTME ACCEPTEDBY: .(,C =EMPLOYEE 0:' DATE: 2 �/ . 2 77 ASSIGNED TO: �,�„L•` EMPLOYEE `Gj DATE: 2-1 2 Date Service Completed (if already completed): SERVICE CODE: u PIE: Fee Amount: 'S Amount PaidJ — Payment Dato �, �j aA a ;LPayment Type Invoice # C # Received W. ENDSED 1111 �,� i, � vti"tti'G 3gs(00013 SR FORM (Golden Rod) REVISED it/77Y2003 l M 1