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SAN JOAQUINCOUNTY ENVIRONMENTAL.HEALWDFPARX MENT <br /> ,.. SERVICE REQUEST ,, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -5 <br /> OWNER/ O RATOR <br /> rAG �� CHECK if BILLING ADDRESS <br /> FACILITY NAM <br /> Pe, <br /> SITE ADDRESS '304 105CV JA) ] r U�r O 1 + O r n <br /> Street Number Direction Street Name l� city Zip Code <br /> HOME <br /> �or MAILING ADDRESS (if Different from Site Address) <br /> ] <br /> (� BOX /9,V Street Number Street Name <br /> CIkeL,a— <br /> '�5rGve- STATE �r� `0 ZIP <br /> PHONE#1 EXT. APN#00/— D 3d.pr3LAND PLICATION# <br /> ( �/<) 77G- /4-/Z 00i - bso .oq 7- og <br /> PHONE#2 ExT• BOS DISTRICT LOCATION dODE <br /> i } <br /> CONTRACTOR 1 SERVICE REQUESTO - <br /> REQt7ESTOR <br /> tJ - leo-'�rS K 13ILLINGSS, <br /> BUSINESS NAME r PHONE# Exry / <br /> HomF,,pr MAILING ADDRESS <br /> 6 0 Z7 FAX ) 7,/`( - <br /> CITY /1 ' STATE A=WIP <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 ap 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard ,, •ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> M PROPERTY I BUSINESS OWNER 101OPERATOR I MA AGER Ltd OTHER AUTHORIzED AGENT❑ T "dh tri <br /> If f1PPLICANT 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 environmentaVsite 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: P h o,5etnu i f o amtrk4- SSS &-n <br /> COMMENTS: t C>SS V, G0nJ—F*"-i(N i4--T`70 <br /> RECEIVED <br /> FEB 2 2 2006 <br /> 3 <br /> ".0 <br /> }� }{ <br /> ACCEPTEDBY: �LlC1 �t EMPLOYFALTHD �A�NT TE: CU) <br /> ASSIGNED TO: � Q(� EMPLOYEE#: jLE�Y�' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (S P I E: 2- .p3 <br /> Fee Amount' (�� ,p� Amount Paid $b O Payment Date <br /> Payment Type � J Invoice# Check# Received By: L41 <br /> EHD48-02-025 ° „$R'FORM.(Golden`Rod) ' <br /> REVISED 11/17/2003 <br /> 4 <br />