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SAN JOAA COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type 4business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER]OPERATOR <br /> '' v, LIZ.. CHECK If 91LU ADDRESS <br /> F ILnY NAME l�, <br /> SITE ADDRESS(00c)l- � �� I() G7> <br /> 5 <br /> net Numbercity Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> NA Qv 1pl ir- 3trsatNumber street Name <br /> CITY M' STATE ZIPCt9 (1Z <br /> PHONE#1 V 7�/ ExT• PN* LAND USE APPLICATION# <br /> (HONER ExT• BOS DISTRICT LOCATION COOE/�71 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME` OR " PHONE$ ExT• <br /> e1to� C✓1 i t (47 O <br /> HOME or MAILING ADDRESS , FAX# <br /> E ( 1 <br /> CITY OAk-LA-A) STT ZIP 6 t <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 HEAbTH 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 F DERAL I <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPEI(ATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTYY,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//v's ?Invent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at theR��>'t is <br /> provided to me or my representative. {{►► <br /> TYPE OF SERVICE REQUESTED: �(�ji� mr, (VA 'Na LQ' DEQ+ <br /> COMMENTS: UCS(Ve lV\ ?(Cqj . •3 Pll ,rQ.� It/1 4J�U I�tt T'G�LLIr1G C11►U SASRONMEt1T/L <br /> -roll-AD <br /> mL -pilin UISS�C%tc �c� �� l N SSTs <br /> �'O(- 6550 4b3 ) C1ICF,QA wrIkA Pt-00-SacOC 3-l3�1 <br /> CCEPTED � ���..�il .FYI EMPLOYEE#: ,� �/� DATE: <br /> ASSIGNED T0: J gl V EMPLOYEE#: DATE: /�a�- <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:�3Q� <br /> Fee Amount: � Amount Paid 3.7�5 Payment Date 49 a 2//I <br /> Payment Type Invoice# as a I Check# Received By: �_ <br /> EHD 48-02-025 -� �i .. SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1�'`�/�iG:'� /��' �►� /7 � / �(�7 <br />