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' SAN JOAQUIN OUNTY ENVIRONMENTAL HEARTH �PAKTMENT <br /> ' SERVICE REQUXST <br /> Type of Business or Property II a FACILITY ID# SERVICE REQUEST# <br /> aC7 ���� <br /> OWNER I 9PERATOR <br /> G CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> F SITE ADDRESS 4 ESI /V' '-De t le/C- G <br /> F Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) <br /> 5 1)t e-T r I LfPo ' Street Number Street Name <br /> CITY � r I^ STATE� zip <br /> PHONE#t " 1 ExT' APN# t LAND USE APPLICATION# (Q <br /> I ) /d 5 -2!G -Za zl iH - _l (mss <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> f 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> I � `„ �� 1�7� CHECK If BILLING ADDRESS C� <br /> BUSINESS DAME �/ I\ !!!/// PHONE# EXT. <br /> Z-CIA7d Sir !/ o�' 23 <br /> HOME or MAILING ADDRESS FAX# <br /> F CITY / O STATE r+ ZIP <br /> BILLING 4–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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: — 5 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> I! IfAPPLICANT 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 /> i <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: �'U y@�A-C 6 s ,P }.��c �,U ,u .J�47�a�.1 10��a e2 <br /> COMMENTS: PA lr1 <br /> a RECEIVED <br /> MAR 17'2005 <br /> ((v0/h';�) 6 �'K SAN JOAQUIN COUNTY <br /> D b ENVIRONMENTAL <br /> ACCEPTED ICY: EMPLOYEE#: ©-;�74 T ( 7 4 S <br /> ASSIGNED TO: .S CC)Tt-b EMPLOYEE#: 5--9[( DATE: 3/(-4o <br /> Date Service Completed (if already completed): SERVICE CODE: fs- P 1 E: <br /> Fee Amount: j 0t7 Amount Paid 7* f tTb Payment Date <br /> Payment Type ✓ Invoice# Check# ��� Received By: � <br /> E <br /> EHD 48-02-025 , rR_1=0RM{GtlE len todl <br /> . Y- - <br /> REVISED 11/17/2003 <br />