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APPLICANT'S SIGNATURE:X PROPERTY / BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 DATE: 7-'7- 1 0 SAN JOAQUI'' TOUNTY ENVIRONMENTAL HEALWEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # POO 2_,c-4, SERVICE REQUEST # 6-RCr -,v70 / 77 Ow ER / OpERATCp / CHECK if ----1- ( Gcr-- 5/Cf41----- *-42k4k.- 1 i BILLING ADDRESS ILITY NAME -- A 1)1 SITE ADDRESS Street Number I Direction ELAQVc ,91-0-6 Stfeet Name k 7 7 ` --- 4/ City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) ) 0 . 42, z). 2( 1.9-2--_ ('2- 2, Street Number ifs r- Street Name CITY 1 SaE , ZIP PHONE #1 EXT. ( ) APN # j LAND USE APPLICATION # PHONE #2 Exr. ( ) II BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR - REQUESTOR .--2:: j 7,4 ik, Ve- ,71 -er-; ,t7,011 CHECK if BILLING ADDRESS BUSINESS NAME PHONE # S .---- EXT. ?3,.2--- HOME or MAILING ADDRESS . .,--0--01-----0.---- FAX # ( ) CITY STATE ZIP 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 i COUNTY Ordinance Codes, Standards, STATE and FEDERAL la s. FEDERAL 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. I TYPE OF SERVICE REQUESTED: 700/ "1/ 6 PAYMEN b a, r- / 7.--- REr.F1VED COMMENTS: An 7 )6 o7 JUL -1 zoo SPN JOAQUIN COUNTY oNMEIsITAL DEPARTMENT / ACCEPTED BY: e, 2 % -.-'--'--; le* EMPLOYEE #: 4 , DATE: ASSIGNED TO: Vrtiric_ EMPLOYEE #: 0/ 3 DATE: 7///4) Date Service Completed (if already completed): SERVICE CODE: /,-.. 0._ .2_ I E: -,60 :2- Fee Amount: lq 230 , ,..),-, Amount Paid a _____ Payment Date () I '1 1 1 0 Payment Type tv----- Invoice # pc_ ... _ A A Check # 1 6 ce Received By: yq--- EHD 48-02-025 REVISED 11/17/2003 /20 SR FORM (Golden Rod) PvZ 0 3 w 0;S I