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�• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IC# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> 5AQ ' fur,+A iAyt1 Jk 5 �e . <br /> FACILITY NAME C q <br /> SITE ADDRESS 1,5 1 S S E 5�Akt, u ValCAf M i,% 1\ l5 Z3 0 <br /> Street Number Direction Street Name Ci Zi Code <br /> HWEor rMAILING ADDRESS (if Different from SiteAddress) <br /> ,t b 3 {� !.(C a(1 f1, Street Number Street Name <br /> zip <br /> CITY STATE y 5 23 <br /> Ltt.1e� G <br /> APN¢ LAND <br /> EXT. USE APPLICATION# <br /> PHONE#1 <br /> 130-f�6 P� o6 - Sri <br /> PHONE#2 FXT. SOS DisTRlcr LOCATION CODE <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REQUESTOR CHECK H BILLING ADDRESS❑ <br /> PHONE# Ext. <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAX# <br /> �oX (2 } 33 D�2` <br /> Cm' L o STA TEC� ZIP 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 ENVIRO�ItvtErrTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> Il also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUfN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: _� % l DATE: "{a'7- C? <br /> PROPERTY/BUSIYESSOWNER❑ OPERATORINIANAGER ❑ OTIrERAUTk10RiZEAAGENT❑ <br /> If APPLICANT is not the i31LLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORINIATION: When applicable, 1, 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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: /� I -fes �� ��.•� �- s7 4 RECEIVED <br /> COMMENTS: <br /> 1614 5 �� ��o �— .� i91� . �S� JAN 2 2 2007 <br /> / 3v �'r'� w <br /> /ir�cy-r GorY�i v�) J�e? t/I �lN ,y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Q /��� . f �7 r�i/+� �` >� HEALTH DEPARTMENT <br /> ACCEPTED BY: V(�t[VIE: [ EMPLOYEE#: j3 Z DATE: ' O <br /> ASSIGNED TO: EMPLOYEE#: 7 DATE: �j 2 l .7 <br /> Date Service Completed (if already completed): SERVICE CODE: Z—, PIE-: 2_4, 0 2- <br /> Fee <br /> Fee Amount: W Lf-7 S- Amount Paid L-1 q S, ( Payment Date ` 2-'2-10 9 <br /> Payment Type Invoice# Check# S Q U Received By: <br /> EHD 48-D2-425 SR FORM(Golden Rod) <br /> REVISED 1111712003 z <br />