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SAN JOAQU.,, COUNTY ENVIRONMENTAL HEALT_ EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> -�-� CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �l 1=-w I �rCtJ t� 0<- <br /> Street Number Direction Street Name City Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �PS�- �/l 1 o iZ <br /> tG'i7Z vN I-/' - -.7 Street Number Street Name <br /> CITY LL--DSTATE ZIP <br /> 1- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (zCl) -3—2) — ( 55 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A ; ��U l CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME PHONE# Ex` <br /> CA-P ��� rN N 1��Rt�" - C�Ns� cT��t�r �r1 FG, — 3 � `T�i <br /> HOME or MAILING ADDRESSFAX# <br /> ( (t)z U �Vl� C= 11i,)"-z L <br /> CITY s'vl"]'lam /00 CcU;Zt)c>VA STATE C� 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 <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 w o e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar�STATE E 1 S. / <br /> APPLICANT'S SIGNATURE: GiC/ DATE: :3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �G�i75l=ZV f G£ Cc N ScX,iA/� <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 ENvIRONMENTAL 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: <br /> COMMENTS: L�' •+E�I�iJ�C' C�/Y�fC�C� <br /> RECEIVED <br /> MAR 0 4 2013 <br /> SAN J0A0 1JIN <br /> COUNTY <br /> ACCEPTED BY: EMPLOYEE HEALTH DEI <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: D <br /> Fee Amount: , Amount Paid j75 _ Payment Date I t <br /> Payment Type Invoice# Check# 3]SZ L, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />