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SAN JOAQUII 'BOUNTY ENVIRONMENTAL HEALTI "EPARTAIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Yn c V� 25-516 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAME clyrCrri r1/1 <br /> W <br /> SITE ADDRESS IW � cant)ant) LpQZ T52-4(00 <br /> I Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ao l ffStreet Number Street Name <br /> CIN STATE ZIP <br /> PH NE#1 E'�T APN# LAND USE APPLICATION# <br /> (�M) 3 0 �7- -� <br /> PHONE#2 EXT. [66i DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( T U /> PHONE �fi,5 y y ExT. <br /> HOME or MAILING ADDRESS FAX# G / <br /> 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 or <br /> 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 JOAQUrN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: nyrn (k k' DATE: �L,1j <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER T ,f)Y❑ OTHER AUTHORIZED AGEN ^ T111tiNd <br /> If APPLICANT is not the BiLLXG 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: C.(s [-/,/91 10,rAJ _ y2,,Lc�4 t 2 <br /> P"M NT <br /> CONMENTS: RECEIVED <br /> MAR 19 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I L/ _-- I EMPLOYEE#: 3 u DATE: 3 It <br /> V <br /> ASSIGNED TO: t-1- EMPLOYEE#: /(�Z� DATE: 3 Q /U <br /> Date Service Completed (if already completed): SERVICE CODE: (GS P/E: z3 D� <br /> Fee Amount: 3,44_5� <"t) Amount Paid 2 Payment ZDate 1 D <br /> Payment Type Invoice# v Check#5 I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />