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SAN JO QUIN COUNTY ENVM01'iWMN'i AL HEALTH DEPARTivIEPl'I' <br /> SERVICE REQUEST <br /> Type o4i Business or Property FACILIT't ID# SERVICE RE1;111SST#;, <br /> ©rJVN+=R 1 OPERATOR CHECK If BILLING ADOWESS 13 <br /> FAcii-iY MAME ( n i Lii <br /> SITE ADDRESS �`I L�� C " � �1 �,��7 <br /> _:5,D <br /> Street Number ❑irection Street Name Cif Zio Cede <br /> ME1or MAILING ADDRESS (if Diff ent#rorrt Si Addr ss) <br /> f '� .,��, 1 ��-' Street Number Street Name <br /> STATE <br /> CITY S+uc � � _ zip <br /> „�, <br /> PHONE#'I Ex'• APN# LAND USE APPLICATION# <br /> (`Z0 ) L�"� -LC.Ck �U (; C�) ' - - ' <br /> PHONE#2 EXT. BOS DISTrZICT i LocxrioN CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTQR y r _ '� j Cx Esc if aILUNG ADDRESS� <br /> r <br /> BUSINESS MXV1E PHONE# _ Ex T. M1y f <br /> HomE or MAILING ADDRESS i , , ! ' r. FAX 9 <br /> /• ii -P <br /> STATE Lt <br /> CITY p / �/ 17- <br /> BILLING AGKNOWLEDGETWE'l')E': I, the undersigned property or business owner, operator or authorized went of same, <br /> acknowledge that all site and/or project species c'EI,7,T2O,\q\�]Ei lT.AL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to rate or my bushaess as identified on this form. <br /> I also certify that I have prepared this application and that jhe Work to e,performed will be clone in accordance with all SAN.fOAQMN <br /> COUNTY Ordinance Codes,Standards—STATE and FEL:EkAI.laws. \. <br /> AI'?PLIGANT''S53GNATURE: ;' �;. r -j t ti DATE: € <br /> r V _ - <br /> PROPERTY 1 BtJ3i1NFSS OWNExirs <br /> 0MRATOR/�IaNAGER L3 OTHER AUT110RFzzED AGENT <br /> -1 At7PLICAof Ae BLLLf2VG PARTY,.prao?, Of aiallaar i-W110A tri sign is required Time <br /> AUT—110RIZA7fION TO RELEASE l('+i FQTkMAT1QN: When applicable, Y,the owner or operator of the propel 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 JOAQU N COUNTY EN-YnZONibIL•NTAL FEALTH DEPARTNMNT 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: j : -, a-i r-, <br /> COA9�hI iJTS' e b`g lad., ✓ x 4 4, <br /> 'Mw ;' 2 8 21"I <br /> HEALTH DEPA,HyT�,;Erfr <br /> yam. <br /> ACCEPTED BY: _., I EMPLOYEE#: DAT`: <br /> AssiGNED TO' yr` EMPLOYEE M I DATE: � <br /> Date Service Completes! (if already completed): SeavICE CODE: � � FIE: j _= <br /> Fee Amount: t Amount paid 0 [' C.) Payment Date <br /> Payment Type � Invoice# Check# Roceived By:,P< <br /> i {; SR FORM{Goren Rod), <br /> EHD 48-02-025 I r <br /> REVISED 11117/2003 .y �, ; „ _�... �_, t t .�`.� •. <br /> ' \ I_:.�. V!. � I� , -�.. r;� � `✓�,� , lr���y j � - � : 'y 1� ,..� 5� !tiv . -L .._ �r_ ,f � '�j,�, <br />