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SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTH WEIPARTMENT SERVICR RF.nITFCT Type of Business or Property CHECKIf BILLING ADDRESS BUSINESS NAME FACILITY ID # SERVICE REQUEST # 1 49 i�A eov2�{5 I EXT. OWNER/ OPERATOR o UIX37 — 6'0 0FAX# SAO NI n r R ( CHECK If BILLING ADDRESS E] FACILITY NAME - STATE / ( A ZIP 53 0 SITE ADDRESS SIM I I �kA(Li4cid of/ec.�tc.n 1 Street Number IrxNon e q5 HOME Or MAILING ADDRESS (If Different from Site Address) CI 1 zl coo CITY SVeet Number tree Name STATE Zip PHONE #I Ezr, ( ) APN # LAND USE APPLICATION # PHONE#2 E.. LOCATION CODE ( ) BOS DISTRICT L'11NTRA('•1'nR /CFRV11-& DTcnrTVQam % REQUESTOR ' CHECKIf BILLING ADDRESS BUSINESS NAME 1 49 PHONE # EXT. HOME Or MAILING ADDRESS o UIX37 — 6'0 0FAX# SAO NI n r R ( )5"3 -b59 CITY STATE / ( A ZIP 53 0 RILf.IN(_ errnvnw. cnncwaon�T_ - --- -----•••-••--�--��,•r��.I' ,, tuc unaerslgneD property or business owner, operator or authorized agent of same, acknowledge [hat all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL la S. APPLICANT'S SIGNATURE: �� &ZY DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT f j / APPLt T� l'l� 'JU O r/Vl Sc>•i f _ (s' of the BILLING PARTY proof of authorization to sign is required Title A t rTunory � Tr�,J6# .uNPUKMAIION: When applicable, I, the owner or operator of the property located at the above site ffth4�FVUIN Ithorize the release of any and all results, geotechnical data and/or environmental/site assessment COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is rncant�N.,o JUL - 7 1010 ACCEPTED Y: ASSIGNED TO. EMPLOYEE #: — DATE: �7 L t r EMPLOYEE #: rD DATE: Date Service Completed (if already completed): SERVICE CODE: L PIE: Fee Amount: 2VF) U Amount Paid J -73�_Payment Date 7 Payment Type Invoice # Check # it/\ S b C� Receive By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)