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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR G-L—I /V(GT61 LSE. <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME . 1 I pD��1 VI --J V'{At2GS <br /> SITE ADDRESS ZOSe�r-) M(l,Tb M 42�.?,A L I N(>6ell 0),37-3(, <br /> Street Number I Direction Street Name city Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (0"5C.> I M I t--rol'l iZ0AI7 <br /> Street Number Street Name <br /> CITY L I N CF-44 STATE G� ZIP 111 <br /> PHONE#1 ExT. APN g LAND USE APPLICATION# <br /> ( ► 401 -G9BG /05 Z40-03 P4- 14-ooZ5,7 <br /> PHONE#2 EXT. BOS DIST ICT An CODE <br /> ( ► ooR <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M (lam �y CHECK if BILLING ADDRESS <br /> BUSINESS NAME /'' 111T,Dl c�t1o�J �t M v�ptl PHONE# 6 6 3 <br /> HOME or MAILING ADDRESS FAx# <br /> 0. A30 y 2/2,0 (Zai ) 3�¢ 0723 <br /> CITY (�p/J/ STATE �, ZIP 95 � <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 <br /> or 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 environmentaUsite 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. AY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: & SAN'JOA 2' <br /> 2-7 t-/lE� / Ety�gO(l/IV <br /> Acrj4f <br /> ACCEPTED BY: C^ 1 lA EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: J <br /> �.� <br /> Date Service Completed (if already completed): SERVICE CODE: GJ�a P/E: ;) IO(7 l <br /> Fee Amount: ;;�c-r-oom,p Amount Pai Q ,bo Payment Date 'f6-7/J6-- <br /> Payment Type Invoice# Check# Rece ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />