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Pay JOAQUIN IIOUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> - = * <br /> SERVICE REQUEST <br /> Type of Business or Property d./ FACILITY ID# \„/ SERVICE REQUEST# <br /> S14RE/V7.1A L O60i✓ <br /> OWNER/OPERATOR - <br /> YYIR!' CHECK If BILLING ADORE55� <br /> FACILITY NAME <br /> t1 <br /> t . /' <br /> SITEADDRESS ��Zg3 ,lQlfTf/ ,r MAn/7ff •{/' ��.'� ' ,L�.gT.4RoP 9S39D <br /> ^ <br /> Street Number Direction — !\ ' I-Street�N:ame f city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 �; <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. ,APN# ^ `��� LAND USE APPLICATION# <br /> _2i•- %.� )]Adt 01 - 03ZSuoov <br /> PHONE#2 E><T.! `j"- y <br /> C� �'` \`�/ BOS DISTRICT LOCATION DE <br /> ( ) U , /7 , <br /> CONTRACTOR/"SERVICE REQ.UESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /V( f•� PHONE# E1r. <br /> HOME Or MAILING ADDRESSr' FAX# <br /> P o . 5o t ) <br /> CITY TG!!ZL- 7CK STATE C, zip <br /> I 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, A E and FEE L laws. <br /> APPLICANT'S SIGNATURE: DATE: — O — ara <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of a thorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 /> TYPE OF SERVICE REQUESTED: NlrgArR 449ADIeVrg0/4 JC44/Ti(B 6/T <br /> COMMENTS: /' /✓,trw,'L .C�'n-a!`/ r Gia nuv� todt fu..4RELIVED <br /> 5 zoos <br /> 'W JOAQUIN COUNT' <br /> ENViRNTAL <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: / <br /> Fee Amount: u, S Amount Paid iA S (E) Payment Date 01 <br /> Payment Type Invoice# Check# as Received By: <br /> EHD 48-02-025 ' S1 FORM(Go'Ideri'Rod) <br /> REVISED 1111712003 - <br />� e <br />