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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY 19 ,SERVICE REQUEST# <br /> OWNER/OPERATOR gypp`` T <br /> D[.,p/J�(/ �//TC./9T CHECK NBILLING LOARrA <br /> FACILITY NAME `� q <br /> SITE AD/D✓RESS /nyj/�y)S� .336 C. /,110/ry Sf .�//�OiV /�'�6lp <br /> "'ii.:.. sr I tlo Street Name C 6 <br /> HOME Or MAILING ADDRESS (If DNferetd from SNe Address) <br /> oo <br /> Street Numler <br /> m Name <br /> CITY STATE LP <br /> PHONE#t APN If LAND USE APPLICATION# <br /> (207) 5/07- 97y3 <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR P }'q <br /> 0� !l 160,ej ` CHECK NBRUNG ADOREaS� <br /> BUSINESS NAME ea,,v U7y,9(,d�'� q� /t,S,SOG. P70J OB — :70-77Ezr. <br /> HOME Or MAILING ADDRESS /00 -fOX 7Z6 FAX# <br /> ( ) <br /> CITY �L.J—�A STATE Uf LP Vd-701 <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 <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: ,�„_��'�. DATE: <br /> PROPERTY/BOsIVEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IiSI 1,epa-4fc1- /�•j/V�C�CK.. <br /> /jAPPLCANT is not the BILLING PAR2Y.proof of atahoritudon 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. 44 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: V ,I <br /> ? 19 <br /> �FgFNO �y <br /> ACCEPTED BY: Cv(r-r'.( S G O EMPLOYEEDATE: <br /> ASSIGNED TO: RX h EMPLOYEEM DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: S�3 PIE: <br /> Fee Amoun 4/5&6a 1Amount Pal 5 6,v� Payment Date �/ <br /> Payment Type invoice# Check# 3 Received By: <br /> EHD 48-02-025 <br /> REVISED 11/1712003 (...k-ap IL t vi etre o.n'a V n + SR FORM(Golden Rod) <br />