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11 <br />SAN JOA U COUNTY ENVIRONMENTAL HEALTH <br />Q EPARTMENT <br />Type of Business or Property <br />® �c-i bt vroroA L. 1= <br />FACILITY ID # <br />SERVICE REQUEST # <br />V&CA"T;*Ito) ,Rw <br />ACCEPTED BY:44 AI <br />5 (o <br />bSC OD {o-7 V7 <br />OWNER/ OPERATOR <br />❑ <br />TG --50C' t N t to (VL <br />L,4—e <br />CHECK If BILLING ADDRESS <br />. <br />FACILITY NAME L) j <br />Fee Amount:'Z <br />Amount Paid <br />SITE ADDRESS lt� <br />I <br />LJ <br />t ,.r -,t i -j <br />I <br />l <br />J-10 fid <br />Street Number <br />Direction <br />Street Name <br />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from m Site Address) <br />B <br />Street Number <br />Street Name <br />CITY `T0 \ 0 <br />STATE -10b)'—ZIP <br />PHONE #'I ExT• <br />LZLO) -Z6 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICTLOCATION <br />6 `f <br />CODE <br />( ► <br />CONTRACTOR / SERVICE REQUESTOR 0 <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />21 <br />BUSINESS NAME PHONE# ExT. <br />(Q.1 <br />HOME or MAILING ADDRESS FAX# <br />CITY Cs ` �&AC*13 0x P` STATE zIP 91 e7 <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 <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 to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FERE s. <br />APPLICANT'S SIGNATURE: DATE: t L-20. 7�p <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR ANAGER 171 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILL/NG ARTY 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: \ S_ <br />k `iJC.a3 T-0 j `0 <br />COMMENTS: <br />RECEIVED <br />JUL 3 0 2013 <br />SAN JOAQUIN COUNTY <br />ENVIROMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:44 AI <br />EMPLOYEE #: �0 <br />DATE: -7 � ` <br />ASSIGNED TO: Q %a�aj <br />EMPLOYEE #: /� 2-2- <br />DATE: <br />Date Service Completed (if already co pleted): <br />SERVICE CODE.. f 9 P 1 E: ' <br />Fee Amount:'Z <br />Amount Paid <br />S" <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11A7/2003 <br />