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SAN JOAQU* oCOUNTY ENVIRONMENTAL HEALTH-aAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Se''vtce I9+A-4-IOy1 AACollf/� 5,&G6� IT S3-e) <br /> OWNER/OPERATOR - <br /> CHECK if BILLING ADDRESS <br /> aro, <br /> rQ V^ 1� I rt <br /> FACILITY NAME Cke vCon S+ct.4-i o n <br /> SITE ADDRESS '3 M0.0 /I <br /> yoD r l huh <br /> at NUmOar I Direetlon I streetI <br /> eet Name CI Zi Code Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i ExT. APN# LAND USE APPLICATION# <br /> (Rcl 1839 -1220 <br /> PHONE#P En. BOS DISTRICT� <br /> (2C1 1 LOCATION CODE <br /> Sl`�� �S� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> leer 4 <br /> REQUESTOR I) 1 eins ELI <br /> tt(A.-Y r� CHECK if BILLING ADDRESS <br /> BUSINESS NAME /` 1 ,.a l Pe-+ro 4,e a(.yl_ PH NE# ExT. <br /> HOME Or MAILING ADDRESS Fax# <br /> I bt(lnOMty 5;+(ee-+ 01462 <br /> CITY 47 422S a n 4-o/\ STATE /'A LP �420 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, oL-A <br /> pe/-raator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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, TATE and FEDERAL laws. �// � �� / <br /> APPLICANT'S SIGNATURE: � t_QQ,(�/2-� 7QC///V!/1Q,L�.J DATE::,/ /(�_�,�'0, -7 l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTL7 ea g-r� %-e4yr <br /> /f 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is <br /> provided to me or my representative. N� <br /> TYPE OF SERVICE REQUESTED: jsr etmdfi It <br /> ECEN <br /> COMMENTS: (tn 9 'ZQQ1 <br /> JAN <br /> SAN JOAOUtt4 c to <br /> TY <br /> HEAL-TH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: lIff DATE: It 4t:f <br /> ASSIGNED TO: N EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: 2 rr' Amount Paid ��5. (TCD Payment Date tom„ O-7 <br /> Payment Type ✓ Invoice# Check# -575773 Received By: � <br /> EHD 4SR FORM(Golden Rod) <br /> REVISEDED 1111 11/17/2003 <br />