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SAN JOAQACOUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CGIlI�� G�✓,o�IGG t�� `/�4?1t� 3�9� <br /> OWNER i OPERATOR _ _ <br /> L4- _ / �r` D CHECK If BILLING ADDRESS <br /> FACILITY NAME�eww"ft G L UE Vc� lG�/� <br /> SITE ADDRESSS. �U/?�i9L 77 <br /> 3//3d Street Number D r iStreet Name C Zip Code <br /> HOME or MAILING ADDRESS (if Different fromSiteAddress) <br /> �!� /"` Street Number Street Name <br /> CITY �x/d^� STATE �W ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# •7 <br /> L209) a s.3 —02 o--i 0 <br /> PHONE ) 7 _a ExT• BOS DISTRICT LOCATION E <br /> �,,if' CONTRACTOR/ SERVICE REQUESTORR 7 <br /> REQUESTOR <br /> / �j�C��y���� �����L CHECK if BILLING ADDRESS <br /> BUSINESS NAME /"/ PHONE# ExT. <br /> s �os�Qv/.-I/eAW00�!-y t'A✓D--sdZ�v <br /> HOME Or MAILING ADDRESS�r D /S/O F(� ) p 7�' <br /> CITY .�/r(�t' UT/ O STATE C� ZIP 1-95-i2-07 <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 thS,3uqrk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAAWi <br /> APPLICANT'S SIGNATURE: DATE: i Olt- <br /> - I <br /> l% <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA R ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is require <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: �ie4'�/✓�wi¢�C/P /fiJG�/��� L✓EGG TILL/i►/�/off 1✓� <br /> COMMENTS: ,O�I�L!/►�Aj �iP/H vtf ��' .ti✓tPE�I-/uy✓ �1� %/ ��/V.rjiit L I'i�%/ <br /> 3 �tGW �iQ!/J�/✓O G✓�-r'—�� ��U�'r/!!/?2i //✓� � ul l/✓ �i9-�/'—i�i`b✓1 <br /> ACCEPTED BY: r YZ'%z <br /> EMPLOYEE#: L%'�f,g-� DATE: <br /> ASSIGNEDTO: �� ��°�"� lL��aKr�S7-✓L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 00 PIE: L/VO 7 <br /> Fee Amount: '1 ✓ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 2-IZ4112 - `'?< �W` � ` / 74/agp�,'`•'•�`�J � SR FORM(Golden Rod) <br /> REVISED 11/17/20032/Z3//2 t�)6�ivc pS� b+-¢ 04W-///i <br /> 3/1 /i!� -- �- <br /> /y//i 3//t//z — �l c,�v•�,�,„ a-f .acov �O�¢ a.,a' t�cv <br />