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SAN JOAQUI BOUNTY ENVIRONMENTAL HEALTI ;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> K (TL N ,fi r"' C9'U ( LD <br /> OWNER/ OPERATOR <br /> I V� L I I NG CHECK If BILLING ADDRESS <br /> FACILITY NAME h u v T 1 <br /> SITE ADDRESS �7 7ZIp <br /> Street Number Direction Street Name Ci 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 /> (Zoo[ ) $3T- 6 75 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> �l <br /> BUSINESS NAME PHONE# ExT.� <br /> �32- 7-906 <br /> - <br /> HOME or MAILING ADDRESS FAX# <br /> 0k4 7 V�. L.P I ( ) <br /> CITY TR AG I <br /> STATE / ,t LP 9S 3 76 _T z] <br /> BILLING ACKNOWLEDGEMENT: 1, 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: 1 �; 2ttk/7it1(.(�_�� DATE: —(I— <br /> PROPERTY/ US_INESS OWN OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 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: CJ`' + / 5Z <br /> COMMENTS: <br /> RECEIVED <br /> FEB 14 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTHF_AJ�DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: / /, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �"�C PIE: Z <br /> Fee Amount: Amount Paid \ �._ Payment Date -7-/ <br /> Payment Type Invoice# Check# Received By: �- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />