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LSCANNED <br /> SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH IPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OERATOR <br /> T-N\� co ty-A <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS `>�2�1Z S �(� �' � OGZC�o <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street`Number Street Name <br /> CITY �_��,. t,� STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 v EXT. BOS DISTRICT LOCATION CODE <br /> �l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> G <br /> I/�(�/1 r a � I yn � CHECK If BILLING ADDRESS ^ 1 <br /> BUSINESS NAME :�( `��'V l V�/l(�Jti ' A PHONE# L ExT. <br /> lqju� �/1 1 1 <br /> 93 <br /> HOME or MAILING ADDRESS �/^ Is a c & l Y � f �Vd c71FAX#L <br /> CITY pC' STATE ZIP <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 C <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&erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE a FE RAL laws.APPLICANT'S SIGNATURE: , �--' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPEOR/MANAGER ❑ OTH AUTHORIZED AGENT LJG t J A l N" <br /> If APPLICANT is not the BILL, GPARTY,proof of aut orization 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 enviromnental/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. PAYMENT <br /> ,o.� ,Y RECEIVED <br /> TYPE OF SERVICE REQUESTED: ���2�-�a-y�+ 6'f- �12�2�,'�,r� GGe� <br /> COMMENTS:j <br /> JAN 17 2007 <br /> SAN JOAOUIN COUNTY <br /> l ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �� � f K, � EMPLOYEE M x/6,8 Q DATE: 7/v 7 <br /> ASSIGNED TO: EMPLOYEE#: 4,�O,, v DATE: 7/©, <br /> Date Service Completed (if already completed): / e $ERVICE CODE: j QQ PIE: 11y0 7 <br /> Fee Amount: a g Amount Paid Payment Date ///,L/07 <br /> Payment Type ✓ Invoice# r!5�'�� Check# 3 9 7 Received By: <br /> EHD 48-02-025 ��lj// �j � ,/SR FORM(Golden Rod) <br /> REVISED 11/17/2003 7,. ( s <br />