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SAN JOAt0J COUNTY ENVIRONMENTAL I'IEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type ofBusiressorProperty FACILITYID# SERNCERECLESf# <br /> (�rn5bllnz <br /> 069015 it q ;l Lvi j�0 03 7o (2170 7 2 g Z <br /> OWNER/ RATO!�- <br /> Cs� g•�„_,1 S S.1-�lN�1� I/yl,e, CHECK If BILLING ADDRESS <br /> FACILITY NAME o Coate'�rNs a�o� <br /> SrMA �. 1 ( S}rCe�— �C12lS)s 3y <br /> SheetNunbei ire ' a a, eJCNY <br /> "� Zip ,e <br /> Ho Eor Nhum Amwss (If Different \k),efrom Site Address) —Vhird siyt-C1- <br /> � <br /> �J Sheet Nulba Sh <br /> CITY , (7_ _I STATE 3 <br /> ZI7-3R <br /> P��p Em APN# LAND USE APPLICATION B V <br /> ( RD ) yal- L1q5\ <br /> PHOM$2 EXT. BOS DISTRICT LOCATN NCODE <br /> CONTR-AfTOR / SERNTCE REQITESTOR <br /> REouESfOR <br /> '^ C"` p� CHECK((BILLING ADDRE 55 <br /> BUSINESS NAME 1l J 1 PI{pf# xr. <br /> �v�tnn C,OYISthtL•tior� 631 , atKl <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIPDAA7, C4 <br /> py <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sane, <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 JoAouIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: rj/Jy/13 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I q"-R-0❑ OTHER AUTHORIZED AGENT l SA1y" <br /> /f APPLICANT/s not the BILLING PARTY.(Hoof of authortzatlon to sign IS requlred Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/she 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 /> TI PEOF SemcEREaEmm <br /> commurs: RECEIVED <br /> MAY 3 1 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DE <br /> ACCEPTED BY: x EMPLOYEE#. ?o DATE. 3 <br /> / / 'l <br /> ASSIGNED TO: '��V1 EMPLOYEE* "') -3 <br /> 6*6 DATE: <br /> Date Service Completed alreadycompletedi: SSWACECODE: ( IqS I P/E 2-3 JS <br /> Fee Amount: 3� S Amount Paid 3 ZS Payment Date 5-131 P-or 3 <br /> Payment Type r/ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />