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SAN JOAQUIN I ZUNTY ENVIRONMENTAL HEALTH DEPW&TMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Se ry;cc S�4T`i'on Gcr lt�or� j g / 5, 5�0 7 - <br /> OWNERIOPERATOR CHECK If Bun.AR MES$❑ <br /> Fret e- a S c o a <br /> FAaury NAME 11 c T/ /</e e.//u � _ <br /> SITEADDRESS �O.f t' �'I rn'i-e Com. Coft <br /> 7a 7ZIP NUMIN <br /> HOME Or IiWuHG ADDRESS (if Different from SHS Addmee) <br /> treat umEer <br /> STATE Zip <br /> CITY <br /> Fxr. APN# � .. _ .� <br /> LAND USE APPLICATION# <br /> Poone#P2 Exr. Boa DISTCT LCCA CODE <br /> ( RIJ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�u , /� CHECK if <br /> BUSINESS NAME <br /> Cl/NM / G ei <br /> HOME Or MAILING ADDRESS 'J FNIR G 7 / 7 <br /> �.o. �x g7 (6a r ► 3 <br /> CITY STATE L'4 , ZAP <br /> IS ON <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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 i <br /> APPLICANT'S SIGNATURE: fle%JZ DATE; 7 <br /> PRoreary/BUS1NE950WNr.R❑ OPERATOR/MANAGER ❑ OT'HERAvruomzaDAGEN'r O� �-,'f' ✓1. . .� 4�_ <br /> If APPL/CANTisnottheBILL/NGPARTY.proof of authorization to sign is required T Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. cut./_+S j I_< �>7�`C� F l <br /> TYPEOFSERVICEREt� /tao)STEX e loe-e— Tool- �Q /ire /e'-ah e774Cfec�'ar <br /> coasems: ( � l (��o� (moo 7JOAQUIN <br /> TY <br /> NT <br /> EMPLOYEE#: G' 2 DATE: I( f3lG <br /> ACCEPTED By: ,U L i V£I IL-� 7 <br /> ASSIGNED TO: A- ( /�L(, EMPLOYEE#: s2- 0 DATE: �/ /,3 C <br /> Date Service Completed (it almdy completed): SERYIrP CODE' �'�� <br /> PIE: ,.30� <br /> Amount Paid 14 aq Payment Date L( <br /> Fee Amoun ��+ ,0�� <br /> Payment Type <br /> Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />