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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT f EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ila# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS® <br /> J o E L_o vrtl�,4cc�D <br /> FACILITY NAME L-DVK�A.��I QRDQE�'ry <br /> SITE ADDRESS 23p Oi{ ��1N to E. P-�• S"T U C11LTOt.) <br /> 02 <br /> Street Number Direction Stree Name Ci ZiCo <br /> HOME or MAILING ADDRESS (if Different from Site Address) t�qG� E. 6-ht,0 NiE <br /> Street Number Street Name <br /> CITY <br /> STATE C1401% ZIP <br /> 9Sz i5 <br /> C�•rp�-rf-pN <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (Za9) 9H S- t°llas-F lft� - 0190 -04 PPC- 09007----j. <br /> PHONE#2 EXT. 80S I]ISTRICT LOCATION CODE <br /> EZ.o'!1 Co 49 - Gold <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> REQUESTOR 1� i CHECK if BILLING ADDRESS❑ <br /> PHONE# � Ems' , <br /> $uSINESs NAME j.ry�• t+t J t RD N 1hE h3T f� _ Zd1 3c�q- 03-+5' <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE C ZIP Ol S�a <br /> a.,00t <br /> BILLING ACKNOWLEDGEMENT: 1, 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 chargjes 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 a d FEDERAL laws. <br /> E <br /> APPLICANT'S SIGNATURE: L.--c I& <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ 7 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1f.4)'�PLICANT 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 /> above site address, hereby authorize the release of any and all results, geotechnical data andlo`r environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is av itable and at the same time it is <br /> provided to me or my representative_ <br /> TYPE OF SERVICE REQUESTED: V%E-VJ SvkL-- S L) tTMcF31 PAYMENT <br /> IZ <br /> COMMENT <br /> 9 �/�0 �,,rr�� -- �,.,,,,�rl SEP 0 2 2010 <br /> SAN <br /> UNTY <br /> ENVIRONME pAL <br /> HATH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z <br /> ASSIGNED TO: r� / EMPLOYEE#: DATE: <br /> r a u-(v S <br /> Date Service Completed (if already completed): SERVICE CODE: 7r PtE: } <br /> Fee Amount: 2 ` �' Amount Paid �_ Payment Date { <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 17/17/2003 <br />