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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I k 12, 0o q3 <br /> OWNER I OPERATOR <br /> B9Yr40O_4 GIQmrIO/A CHECK NBILLING ADDRE55O <br /> FACILITY NAM <br /> SITE ADDRESS 26t3S! N 5T4TE PD.JTE �i X. /�C�}MP� °Iszzo <br /> Street Number 0irectbn St.t Name rl C' ip Code <br /> HOME or MAILING ADDRESS (If Dwerent from Site Address) <br /> $tAH Number Slreel Name <br /> CITY STATE ZIP <br /> PHDK#1 EXT. APN 0 LAND USE APPLICATION# <br /> (201) JI& -010 .V L906 -090 - S8 PA - 05 bo 3 z1 <br /> PNaE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR µ(V6 TDI <br /> CHECK N BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> DIU.ON M 0 otilw�1 33 -66f ' <br /> HOME or MAILING ADDRESS FAA# <br /> 0Co-1 ) 33 -o7Z3 <br /> CITY W0i STATE CA LP 65524 <br /> BELLING 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 OPERATOR/MANAGER ❑ OTH R AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING P,lR 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 /> COMMENTS: �C j 92 HEECENED <br /> AUG 12005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: / Q <br /> ASSIGNED TO' — EMPLOYEE#: DATE: <br /> Date Service Completed (R already completed): SERVICE CODE: PIE: <br /> 3 <br /> Fee Amount: Amount Paid D 1 Payment Date br <br /> Payment Type ,/ Invoice# Chhe�ck## /O Q�',1t Received By: <br /> REVISED 1/77/2003 D l,/ v r v" s q <br /> EHD 'r SR FORM(Golden Rod) <br />