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a <br /> SAN JOAQ COUNTY ENVIRONMENTAL HEALTODEPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J:jV&)&y La),Aj-� ( :I S�-00 Lf 9 1 <br /> OWNER/OPERATOR I'• �.- , <br /> iYA, CHECK If BILLING ADDRESS <br /> FACILITY NAME Wv4 1`iit <br /> SITE ADDRESS `�? Z�L S ��l� -�'v <br /> Street Number I Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) "1 �a p <br /> Street Number Street Name <br /> CITY <br /> - �/� STATE CA ZIP 157 Z <br /> HONE#j ��� ��ExT� APN#���� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME Qo r �� PHONE#cju ��� �����/� EXT. <br /> HOME Or MAILING ADDRESS �/� FAX# <br /> CITY STATE ZIP <br /> t3 cp� <br /> MILLING 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,STATEFE RAL laws. <br /> APPLICANT'S SIGNATURE: � � r/;" <br /> � DATE: t � 10 J <br /> �7)PROPERTY/BUSINESS OWNER❑ OPEOR/MANAGER ❑ OuidAUTHORIZED AGENT LXX l JV I� <br /> If APPLICANT is not the BILL GPARTY,proof of aut Orizadon to sign is required Title <br /> AUTHORIZATION TO RELEA E INNFORMATI N: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. P"MENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: <br /> JAN 17 2007 <br /> C:i2 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: s �. e% EMPLOYEE#: DATE: l//7/0 <br /> ASSIGNED TO: �_1 � EMPLOYEE#: Lfv-'<0" DATE: ``77/®,-> <br /> Date Service Completed (if already completed): / SERVICE CODE: 'S 0, P/E: Ile-10 <br /> Amount: ag5 Amount Paid �g Payment Date <br /> Payment Type t/ Invoice# l S'��5 oco Check# a 3 Received By: / <br /> EHD 48-02-025s-2 fit/ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 A`, <br />