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' SAN JOAQUIWOUNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR Ra, -e^,p_ C j CHECK if BILLING ADDRESS❑ <br /> FACILITY NAM' /!l�r�� Z� U1® <br /> SITE ADDRESS 13� bI.�Q P�1!L/ �Q�( Trak' 9 537"7 <br /> Street Number Direction treet Name 7 CI� ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ogvi ) 330- E99F <br /> PHONE#2 EXT. BCIS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS C <br /> PHONE EXT. <br /> BUSINESS NAME � Cubo S-e( &,--s q) pJSp!Q <br /> HOME or MAILING ADDRESSFAx# <br /> 1036 (L901) <br /> CITY ®t'L JLa Aj U STATE C# <br /> ZIP 9 S 3 6 <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 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:: D//',��� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTS (-/�'l yLcy <br /> !f APPLICANT is not the B/CLING 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 environmentaUsite 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. ee <br /> TYPE OF SERVICE REQUESTED: (gle'��d 9 lzt /J V e J LL <br /> COMMENTS: bd-a -7q 9-0'23�3 p yon PAYMENT <br /> RECEIVED <br /> APR 2 6 2012 <br /> SAN JOAQUIN COUNTY <br /> E.W RO N M ENTAL <br /> DEMBDIENT <br /> ACCEPTED BY: EMPLOYEE#: I DATE: 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (i ready Completed): SERVICE CODE: PIE: <br /> Fee Amount: J Ar>Rount Paid �', Payment Date 1 z'Y Z <br /> Payment Type l D a Invoice# Check# Received y: <br /> EHD 48-02-025V I L4 SIR FORM(Golden Rod) <br /> ^^^^ <br />