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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5200 �F 3�u3 <br /> OWNER OPERATOR q <br /> CHECK If BILLING ADDRaSS Er <br /> FACILITY NAME C '/ a�t� <br /> SITE ADDRESS �,GD S wl� 66 � A!/ v <br /> Street Number Direction Street Name/C.LJ City <br /> 21 Cotle <br /> HOME orA&M ADDRESS (If Different from Site Address) /��S GV W4l�-rlwePE <br /> Street Number Street Nam [• <br /> CITY rSTATE C�.A zip �/9SQ <br /> PHONE#1 (� 7 /Ex,. APN Y LAND USE APPLICATIONR 7 T/ <br /> (, 0 1 107-42e7—4& ��--Os—/ <br /> PHONE#2 EXT. SOS DISTRICT LOCATON CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr, G <br /> �OsG,�[. �ND(� Z CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESSQO �t7 /8� F. viG) �!-d7�3 <br /> CITY 0 % STATE i�/rif/r ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 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 /> I also certify that 1 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 d FEDERA laws. —7 <br /> APPLICANT'S SIGNATURE: 9 DATE:: <br /> PROPERTY/BUSINESS OWNER 13 ERATOR/ AGER 13 'OTHER AUTHORIZED AGEIyTO—/ <br /> I,fAPPL/CANT 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: <br /> NT <br /> COMMES: C'/ZZ-1, 5- RE <br /> 7 i2 � �C23 �j*i2°�Tu�.� Jud 2 2AN 2005 <br /> UNV�(i0 19itJ) StJj0pONMEMEM <br /> DEPAR <br /> ACCEPTED BY: L t L' t �J (� EMPLOYEE#: O 3'Z'/I ATE: 7 22 OS <br /> ASSIGNED TO: ESCo lm EMPLOYEE#: S)ciT DATE: -7 2-i(oS <br /> Data Service Completed (N already completed): SERVICE CODE: Sts PIE: <br /> Fee Amount: - &-fr ,U Amount Paid Payment Date � p <br /> Payment Type Invoice# Check# Ret:eived B4: <br /> EHD 4e-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />