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` SAN JOAQU#ouNTY ENvmoNMENTAL HEALTH 'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /„_� _ ,_,C v ��� ���5 J��^, �,r/JY {►,t��j' ,�,. /• CHECK If BILLING ADDRESS <br /> FACit.RYMAIM • b <br /> SITE ADDRESS <br /> 5- Street Number I/Dire"On (� (/ me c1tvZi Code! <br /> HOME Or MAIUNG A DRESS (If Difrer/ rtt efr Siterress) <br /> ' <br /> 7 na t� V ' Street Number Y Str tVName U <br /> CITY / STATE ZIP 1 <br /> PHONE#1 ( Eirr. APN# LAND USE APPLICATION# 7 <br /> (VI51 5-/6- -6 76 123 —OZ-61a <br /> PHONE#Z Exr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK IfBILUNGADDRESSO <br /> BUSINESS NAME / Y PN NE�i) !l-7 <br /> HOME or MAILING ADDRESS Z96C �i o d ' Fax# <br /> akov k %Oo <br /> ) 3 /S9/ <br /> CrrYSTATE //{}- ZIP '7 <br /> BILACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or pr(Iject specific ENN`IR0N1,IFNT.XL HE.xLTH DEP_aRTNIENT hourhI charges associated Nvith this prgject <br /> or activit-,I 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 pe ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE apd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: T} Q <br /> PROPERTY/BITS P1ESSoRNER)a opatkToR/xf.ANAGER ❑ AGENT13 <br /> If.4PPLIC.INT is riot the BILLLV'G P.4Rn proof of authorisation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA'T'ION: 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 en-vironmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONXIENT L HEALTH DEP aRTKIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ., ,(MENT i <br /> TYPE OF SERVICE REQUESTED: i J RE <br /> CONVENTS: 7 2005 <br /> N jOAQUIN COUNTY <br /> SAN <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: � DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: PIE: -2-Z <br /> Fee Amount: Amount Paid 1�7 D p Payment Dafka`j S <br /> Payment Type Invoice# Check# 13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />