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SAN JOAQUu7'COUNTY ENVIRONMENTAL HEALT00,6EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 � 6 � o� � <br /> OWNER/OPERATOR L/ / �/�L CHECK if BILLI1GADDRESSpSf <br /> FACILITY NAME / <br /> SITE ADDRESS ` �s� W Ll hGo�lti WGt't- r-C,� SN^ ST"t l'1' �ZO <br /> / Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (I Di erent from Site Address) ✓ <br /> h/LbGI Street Number / Street-CITY � $T TE ZIP <br /> PHONE V Eir' APN# LAND USE APPLICATION# <br /> 7 CJ�vd 1{l 0 4 3 <br /> PNONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ) oZ y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C <br /> //'OJ CHECK If BILLING ADDRESS <br /> BUSINESS NAME �l Ln�/ G / PHONE# ExT <br /> / HOME Or MAILING ADDRESS �f- �o�Q ` FAX# <br /> j CITY STATE 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 a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan r A an FE laws. �I J <br /> APPLICANT'S SIGNATE; <br /> PROPERTY/BUstNESs OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <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: �oa t G1-k ( .lam 4� <br /> PAYMENT <br /> COMMENTS: RECEIVED <br /> FEB 0 7 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: ��;, ,,� i EMPLOYEE#: <br /> ASSIGNED TO: � �vhZh EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: y—Z 3 P I E: ! b o 1 <br /> Fee Amount: 3 7 Amount Paid h- — Payment Date <br /> Payment Type ✓ Invoice If C Check# " Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />