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ClAiN dvAYUJIN I.UUIN1 Y EINVIRONNIEN1AL 111EAL1H LIEPARIMENf <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> 7 Lin/ CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 'q57 <br /> v q g was F k" —1Lf <br /> Street Number Direction Street Name I� Ci � r^�-1 Zip Code <br /> HOME orMAILING ADDRESS (If Different from Site Address) gS24 U <br /> OO �raU�l cf� Street Number Street Name <br /> CITYLO , , STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (2-°i) X29 5'11 'S- ?A 26 <6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> R.EQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS I FAx# <br /> f ) <br /> CITY C STATE ZIP <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 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: xz 3/ Q <br /> PROPERTY/BUSINESS OWNER❑ 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 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: A)IT2 _L')A-0 iN6- .Sates -S:4-e /TlrA/L t'r <br /> COMMENTS: /// }�Pj j//� ��y/�/w- / v,�� RECEIVED <br /> A65�7 jlegJ�Etd�) 3 a <br /> NOV 3 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HIMLT <br /> ACCEPTED BY: ��,L- tV IIQ,..'� EMPLOYEEM ?_( mrbATE:1 I, 3�G <br /> ASSIGNED TO: FA7-b EMPLOYEE#: Yc. DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: _,' Z.y PIE: LCo.CiZ <br /> Fee Amount: -9 L1 6 ,.J Amount Paid Payment Data <br /> Payment Type Invoice# Check# Received By:5�i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />