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SAN JOAQUIN COUNTY F.N'VIRONMENTAI,HEALTN DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ` FACILITY ID# SERVICE REQUEST# <br /> I 00 2� x <br /> OWNER 1 OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME . : <br /> SITE ADDRESS Y"ti I[le f �� f 7�f <br /> I Street Number Direc C <br /> HOME or MAILING ADDRESS (If Different from Site Address) S U C/ '61 <br /> 12� Number v <br /> CITY 4TATE <br /> PHONE Al EXT. APN# LAND USE APPLICATION <br /> (656) Z2—(�J— 13 'Z <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Te <br /> d <br /> __ <br /> e`S- BILLING if BING ADDRESS <br /> BUSINESS NAME -TJ f "? ! - PHONE# ` V `Exr <br /> (� r <br /> HOME Or MAILING ADDRESS --^�Y� �'^ ('• ' /j / FAx# ) <br /> Quelfa <br /> CITY A !./r Go STATE C! LP <br /> BILLING ACKNOWLED EMENT: 1. the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL fI I DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certih that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COITNTY Ordinance Codes,Standards,STA and F w <br /> ERAL las. <br /> APPLICANT'S SIGNATURE: � 1 D,%TE: <br /> PROPERTY/BUSINF_CS OwNT.R Cx� OPER R/MANAGER OTHER At"rHORIZED AGENT❑ <br /> If APPLIC9.VT is not the BILL/.•4G P.4RTY,proof of authorization to sign is required 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 /> infiormation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time i <br /> provtisided to me or my representative. A YM <br /> TYPE OF SERVICE REQUESTED: CF�V^ANr <br /> COMMENTS: \O <br /> C'Ov,���� <br /> y �ogQ 15 zo19 <br /> ACCEPTED BY: EMPLOYEE#: DATE: DE�TM NT <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: PI E: bU'Z <br /> Fee Amount: \S Amount Paid l S Payment Date M <br /> Payment Type 11 Invoice# Check# 17193 <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />