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SAN JOAQU...:OUNTY ENVIRONMENTAL HEALTH L—PARTMENT <br />SERVICE REQUEST <br />9m <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�2rmFUEL1;�6 FA6,i, y0177 <br />7 <br />EXT. <br />�y�- 9��a <br />OWNER /OPERATOR Q <br />G N 1`0� <br />CHECK if BILLING ADDRESS O <br />FACILITY NAME C , 1�ivIL � <br />/'1 � 30'2 709 <br />SITE ADDRESS <br />STATE C /]. <br />�Ll v/ TY A(iK4JA`f <br />P <br />ENT <br />Sroc KTP, .t> <br />y�sz/ 9 <br />/(�g � � Street Number <br />Directton <br />Street Name <br />ASSIGNED TO: <br />citif <br />Zip Code <br />HOME or MAII ING ADDRESS (If Different from Site Address) <br />�o <br />��I �(�ls/� CA �Yv ✓ ;LC/Y3 <br />(.001 Street Number <br />Street Name <br />CITY <br />A� MUS <br />5% 'o <br />S <br />QA,4. ZIP / yS o 3 <br />i�� <br />SERVICE CODE: 1 G1 TJ <br />PHONE #1 EXT <br />APN # <br />LAND USE APPLICATION # <br />7 7 <br />5 <br />1 P46 <br />Payment Date SZ4 <br />PHONE #2 EXT. <br />BOS DISTRICT <br />__7� <br />LOCATION CODE <br />Check # 3�(,7 <br />Received By: <br />610 S <br />0 1 <br />CONTRACTOR It SERVICE REQUESTOR <br />REQUESTOR �)n�^) _ <br />N D6) 5 /►� 1 <br />1 / , <br />5'j <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />comy� P�t2y <br />PHONE # <br />',16 <br />EXT. <br />�y�- 9��a <br />HOME Or MAILING ADDRESSFAX# <br />3o mAw AU6 �u I ,/ Os- <br />SAN JOAQUIN COUNTY <br />ENVIROMEN <br />CITY `5 /IC -j—() <br />STATE C /]. <br />ZIP <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 />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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: J- Z I- l I <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT J3 j7LO J%c I /f-74,1 GAI- <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/site 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 />TYPE OF SERVICE REQUESTED: <br />5'j <br />COMMENTS: <br />MAY 2 9 2014 <br />SAN JOAQUIN COUNTY <br />ENVIROMEN <br />HEALT}.r I)EPARTTqAL <br />ENT <br />ACCEPTED BY: <br />%�' ��-- <br />EMPLOYEE M 7 v <br />DATE: 1 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 1 G1 TJ <br />PIE: '-361? <br />Fee Amount: <br />— �� <br />Amount Pale37S <br />Ulf <br />Payment Date SZ4 <br />Payment Type <br />Invoice # <br />Check # 3�(,7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />