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SAN JOAQUI*,�.OUNTY ENVIRONMENTAL HEAUtl6p,EPARTMENT <br /> SERVICE REQUF,'ST i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U -� <br /> OVYNER10PERATO <br /> �j BILLING ADDRESS <br /> FAcil-g,Y NAMll � <br /> kILIIL�� CA U?Y-:�J <br /> SITE ADDRESS � ^ , �yr <br /> Street Number Di�reetion 5 Ntreet amen t'Zip Code <br /> }TOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> j CITY - STATE ZIP <br /> ! PHONE#1 ` APN# 6 LAND DISE APPLICATION# <br /> { <br /> PHONE#T E)T• DOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> • CNECKIf BILLING ADDRESS j <br /> BUSINESS NAMEI! ,,_ + PHONE# ���r Q Exr. I <br /> HOME or MAILING ApIPRESSFAX# <br /> CmfSTATE ZIP <br /> KILLING 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 JOAQUN . <br /> COUNTY Ordinance Codes,Sta , TE and FEDERAL laws. <br /> APPLICANT'S SIGNA DATE: <br /> PROPERTY/BUSINESS OWNER❑ P ORI MANAGER ❑ �OTHMERAUT1iORIZEbAGENTLt311 <br /> _ <br /> IfAPPLrCANTis not theBlLLxGPAR 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 environmentallsite assessment <br /> information to the SAN JOAQLmq 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 Si:RVICE REQtEESTED' N 17-12+ C_ +�,a.r rv�s- S p f 1_ amu-c 7y4-,6 r G?T d!1-G C7. �' <br /> i R <br /> OAOUIid C u� <br /> d SAN SV1FtdNMEN�A NS <br /> ACCEPTED BY: �1<!cf�I 4th MPLOYEE#: 2�Zr DATE: "7 r2� 6 — <br /> ASSIGNED TO: e—�s—ryO—A 4 A EMPLOYEE#: 7�T DATE: —7 <br /> Date.Service Completed (if already completed): SERVICECODE: 5'2 P1 E: O 2:' ; <br /> i <br /> Fee Amount �'v Amount Paid Payment bate . `Z <br /> Payment Type invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> DEVISED 11/17/2003 <br />