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Type of Business or Property <br />City StateLA <br />APN# <br />Ext.BOS District Location Code <br />Requestor Check if Billing Address <br />Ext.Business Name <br />City State Zip <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments: <br />Employee#:Accepted By: <br />Employee#:Date:Assigned to: <br />Service Code: <br />Amount PaidFee Amount: <br />Received By: i >Invoice #Payment Type V <br />SR FORM (Golden Rod)EHD 48-02-025 <br />07/17/08 <br />FACILITY ID # <br />Eg.c’k tE <br />Stroot Name ________City <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />Zip Code <br />Lrt <br />( <br />Payment Date <br />Phone #2 <br />() <br />Phone #1 <br />( ) <br />^service request # <br />Check if Billing Address D <br />ftp. CO <br />Home or Mailing Address <br />________S>- C-htAcA<e£. <br />_____________________________STATE C fi Z|P ‘KZko <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific Environmental Health Department hourly charges associated with this project or <br />activity will be billed to me or my 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 Joaquin <br />County Ordinance Codes, Standards, State andJ^DER, <br />os!Id <br />Phone # _ „ <br />Fax# <br />J__)_ <br />C 0 <br />ft-Eco <br />Site Address <br />___________________Street Number <br />Home or Mailing Address (if Different from site Address) <br />L/ /< <br />Ext. <br />/Viorel is <br />Date Service Completed (if al/eady completed): <br />Street Name <br />Zip <br />d 5 ■75'7 <br />Land Use Application # <br />______________________ Date: <br />Property/Business Owner Operator/Manager 0 Other Authorized Agent <br />If Applicant is not the Billing Party, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sile assessment information <br />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 <br />my representative. <br />4 / S’a, oo <br />Check# IqI2>. <br />I Date: <br />>7»7Z/f <br />P,E: /IppTO <br />Ljn <br />CONTRACTOR / SERVICE REQUESTOR <br />PIXH LsA <br />QprS <br />Owner / Operator <br />_______meHT Iho <br />Facility Name (x <br />s <br />Direction <br />from Site Address) , / <br />/Vl I r"&■ / /L ’ Street Number