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SAN JOAN ODF '~OUNTY ENVIRONMENTAL HEALT '?EPARTMENT <br /> SERVICE REQUEST -r4 <br /> Type of Business or Property FACILITY ID# 7: SERVICE REQUEST# <br /> 5 rya <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> `f s <br /> FACILITY NAME <br /> SITE ADDRESS t.✓75 0 rksSON C,.,,,,� CVQ L I p <br /> S30'-J <br /> Street Number Direction Street Name city ZIP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT 7 LOCAT104i DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> � G L. <br /> BUSINESS NAME PHONE# ' <br /> Z , o <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP 9 5 3S 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,ST ind FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: S— Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT 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 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: st„/l <br /> c ¢Li,i, ( /yr ��l�'�05 ►""r�L�v� REC VED <br /> 1 1 � �J MAY 2 7 2005 <br /> tY -fir 3 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED EMPLOYEE#: 506 C DATE: O #. <br /> ASSIGNED TO: ✓ ,�� EMPLOYEE M Q�- DATE: 4 <br /> Date Service 15omplated (if already comple d): SERVICE CODE: l 5 P 1 E: D <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice Al Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />