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i <br /> SAN JOAQUM ` OUNTY ENVIF6NMENTAL IIEALTF n.EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS® <br /> HCArZY 0_.,9 TOAV SH6A <br /> FACILITY NAME <br /> SITE ADDRESS/ Rk�y 9 S 37G <br /> eet Number Direction S et Mahe - Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 1601 W L I'V C-0 1,A/ &0.4-p <br /> Street Number I Street Name <br /> CITY �✓ STATE GA ZIP I 5-Z-05-Z-07 <br /> SPU�kttJ <br /> PHONE#1 EAT' APN# LAND USE APPLICATION# <br /> ( ) 478 LSSS j�sj'ISt)-W,S+� /B7-JG-l3 ,9 d� O C� <br /> PHONE#2 EM BOS 61STRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q1/ CHECK If BILLING ADDRESS <br /> a e-X/ <br /> BUSINESS NAME iJ f PHONE# ' <br /> S/6GFA4ED 6N61Al IV G / j✓UG _ W'7 9N3 - Z0t1 <br /> HOME or MAILING ADDRESSFAX# <br /> 1(0'/S C.JlAti IV,+D 0 AV6-5 (Lo ) q t(2- 024 <br /> CITY !) mLKi,7 4) STATE G If ZIP q ru y <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, STATE and FEDERAL law . <br /> APPLICANT'S SIGNATURE: ,( 41' DATE: /,�Z7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1f APPLICANT is not the B1LLflVGPAR 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 /> inforrmfion to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as available and at the same time it is <br /> provided to me or my representative. ENT <br /> TYPE OF SERVICE REQUESTED: ,s RECEIVED <br /> COMMENTS: O <br /> SEP O '2004 <br /> C7/ 7/,4,/ YPDA t ;,, (,� <br /> cl--Z- ,e, L-00- � ®11444%A1 SA ENVVIIRONM NOTALrab TM <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid 5• Payment Date <br /> Payment Type I,' . Invoice# Check# O "Li_; Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />