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SAN JOAQL COUNTY ENVIRONMENTAL HEALT. EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Q l y� P Jia <br /> SITE ADDRESS y 7�S L GU f�-�'� �r CL� S-1—ol�L�•c�ti,� `t >?i� <br /> Street NumberDirection Street Name C Ity Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) q D K C) (� I 'A( V1'( <br /> Street Number Street Name <br /> CITY STAT zip S i�•��t, fan Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2-t) LA //q!- 1 -- Ct I q.� <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 /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 ENvtRONMENTAL 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,Sta6ndardss,, ATE and FEDERAL laws. / l <br /> APPLICANT'S SIGNATUPDATE: <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/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, 1, 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. II <br /> TYPE OF SERVICE REQUESTED: uc� v at,t I/ -L/ upS / <br /> COMMENTS: O .(� � � ( MqR 26�V'FD <br /> SAN 2014 <br /> F JOAQUtN C <br /> NFgLTN Rop Aq tt 4t <br /> ACCEPTED BY: l�- EMPLOYEE#: DATE: L 6 <br /> ASSIGNED TO: r �a rt,�Y� t EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready completed): SERVICE CODE: l P/E: <br /> O <br /> Fee Amount: 12 > �, Amount Pa' Payment Date 312&11 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />