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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICEWQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SIZ o o Y to <br /> OWNER 1 OPERATOR <br /> 21 <br /> (n` - �n e, ��I�� G <br /> FACILITY NAME w Y CHECK if BILLING ADDRESS <br /> ` L <br /> SITE ADDRESS Z�?2—S I Cr S+, 7—(-41A&em, 2——6 CP <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �f— Q ' Street Number Street Name <br /> CITY E 611yo ,a, STATE C4 zip <br /> P NE#1 EXT. APN# O!a 7-Z 3t']�(� LAND USE APPLICATION# P-- <br /> 4161 05-(P5oo . . . 1 A &- t t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> ( ► 2�5� <br /> HOME or MAILING ADDRESS FAx# <br /> F6ITy <br /> F t lL 0-LAk C STATE ZIP (?'-s .Z <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNAT C DATE: Z-' <br /> PROPERTY/BUSINESS OWNER OPIi TO 1 MANAGER ❑ TH AUTHORIZED AGENT F <br /> IfAI'PLICANT is not the BiLLiNG PARTY,proof of authoriza ton to sign is required Tette <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: <br /> Af FEB p 200 <br /> •i� s fd Go,Q�s .SS SR�n'JOAQUIN cOUNn' <br /> H�rN 1)N1,E at <br /> ACCEPTED BY: LCL E EMPLOYEE#: 6)42—f DATE <br /> ASSIGNED TO: C'0';M EMPLOYEE M 52 q DATE: {} <br /> Date Service Completed (if already completed): SERVICE CODE: L3 LS, P I E: <br /> IH Amount Paid 1 Q S S Payment Date � <br /> Fee Amount: ~Pt l $t,00 C) ',,I b <br /> Payment Typo Invoice# Check# Q b Received By: �G <br /> SR FARM(Go14en"k6d) ' <br /> END 48-02-025 _. <br /> REVISED 11/17/2003 <br />