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SAN JOAQ, N COUNTY ENVIRONMENTAL HEAL' __DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> R a2 S 1-f��Z int✓ �I �✓Gi I—� <br /> FACILITY NAME Lk`q \J© n 4 x)X t* 2— <br /> ITE ADDRESS ,Cr �'vy) C�} C? S ZI <br /> Co Z6 LOWer S2' c�'Y►'1 en`�i ��_ �, � oC. <br /> Street Number Direction Street Name cityZi Code <br /> Ho M or MAILING ADDRESS (If Different from SiZe'Address) <br /> M1 C0 3 Street Number Street Name <br /> CITY STAT ZIP 9.9 � <br /> M A A/i�=c. 4 c_or7 7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> f ( )S5`i -- 3 S5--6 S6LJ -.�,o <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> (2;ocj) 62q — S i ng t: 3 c l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1—ICHECK if BILLING ADDRESS <br /> fldZS0f� J2 �,1✓ S1n✓�� A <br /> BUSINESS NAME PHONE# EXT' <br /> 1 4A X M 1F C Ll 2. 1 C 2- ( 1'-C- 2 Jt 6'z 9 8 Z2 51 <br /> HOME or MAILING ADDRESS FAX# <br /> /63 izv� y, �lttll AL1- ( ) <br /> CITY J"SfiN 12 STATE ZIP 9 S jJ 7 <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 ENvIItoNMENTAL HEALTH DEPARTTViENT 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,STATE and FEDERAL laws. 7 <br /> APPLICANT'S SIGNAi czrs)jC<,VI-I ATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ /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 <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 ENvaoNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: F k->4 Qui(�l l�� G�jPAYMENT <br /> COMMENTS: 3-2z4-/5- 3RECEIVED <br /> 3a <br /> MAY 2 8 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROIIIIENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �r►rW� EMPLOYEE#: DATE: .S i t 81 L <br /> ASSIGNED TO: (N L SJ�/1/\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� o <br /> Fee Amount: �y" Amount Paid s�, °' . Payment Date <br /> Payment Type �' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />