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i <br /> SAN X) QUI OUNTY ENVIRONMENTAL HEALT,'— )EPARTMENT <br /> - ` ' SERVICE REQUEST <br /> Type of Business ar Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> P,4 V 1 ❑ <br /> FACILITY{NAME C� <br /> SITE ADDRESS 6 3e 5 S '4 GC ST I AJ kOA D InA N TE CA 9'!57 36 G <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 63036 RC"4 Q <br /> /Street Number Street Name <br /> CITY STATE ZIP <br /> MA i�/TF-e eA 9!!�-3 3 7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATI N# <br /> vo'�) '5- - 4wr -afo P o - o <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> / GLS 3JV CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# // ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY L 0 C—�L STATECA ZIP 61-,5-3 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 -,�7y r d <br /> PROPERTY I BCSINESS OWNER❑ OPERATOR/ NAGER ❑ HER AUTHORIzED AGENT ❑ <br /> f IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tine <br /> f 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: fJ -gam <br /> COMMENTS: P Y 1 <br /> FES 2 6 2009 <br /> 3 y <br /> SAN JOAGIt]IN GQUNTY <br /> EWA- <br /> ACCEPTED BY: EMPLOYEE#: EALTHSTM <br /> ASSIGNED TO: EMPLOYEE#: CJ�--� DATE: <br /> 10�L— <br /> Date Service Completed (if already compieted): SERVICE CODE: 2/2_, PIE: <br /> Fee Amount: ��(}� `� Amount Paid a , i-d Payment Date (L/,:9 <br /> Payment Type Invoice# Check# g� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2403 <br />