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6 4 A <br />SAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Property <br />ec GWR fC /tdX c oy✓ AFl <br />FACILITY ID # <br />L 3.9 S <br />SERVICE REQUEST # <br />OWNER / OPERATOR _ / '/� _ <br />sw7v%c /I✓ �/ ! ® �� f,G jc �/[�T �f ��.9®, _ ® `SCK IfBILLING <br />i /> <br />DDRE f/ <br />FACILITY NAME ® �y �,n1AIL 6/- f ®�!®L®( s' G®/'L <br />v�®CJ® <br />®Y^3 6 ® E <br />SITE ADDRESS 3 ®/ �®<�` <br />Street Number <br />n Flf <br />i Direction <br />I�Ga/Tr�GV c �hf�® <br />Street Name <br />/ �17573-77 <br />cityZi <br />CITY Jr®® O % <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address)ZE( <br />Street Number <br />/ a <br />Street Name <br />C"® <br />CITY STATE ®,,? ZIP <br />/`— <br />9 U <br />PHONE #1 ExT• <br />(209) 6(r— YVI b <br />APN # <br />573 0 C2 ®d <br />LAND USE APPLICATION # <br />Received By: <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR iC/Y G L ReR L <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME/ 'y (A1^1C�^/® ,� ®�©�A <br />©�� !r <br />PHONE <br />®Y^3 6 ® E <br />HIS MAILING ADDRESS <br />R-0 / /o <br />FAX # <br />(;of) <br />DATE: <br />CITY Jr®® O % <br />STATE G ;J <br />ZIP c / <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 />r <br />APPLICANT'S SIGNATURE: DATE: /�/o ,o <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER [3 OTHER AUTHORIZED AGENT g lv® e®d/L eWJ"1,,A1 E/e <br />If APPLICANT is not the BILLING PARTY_proof Of authorization t0 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: <br />COMMENTS: R®®I®®L ! ��✓Y !- �R%I�% /®� ®//vs ��GG,r//v C // <br />®C'� Al <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: I// 1 T <br />ASSIGNED TO: �P <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount:Amount <br />Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />