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QFRVirF RFOITFST <br />Type of Business or Property <br />v y - — FACILITY ID N <br />SERVICE REQUEST # <br />VIC )(J -J ?) 1 UU <br />OPTED I 1 �'t`�IJ�l <br />EMPLOYEE *: <br />OWNER/ OPERATOR <br />ASSIGNED TO: 1'�.� <br />tU <br />EMPLOYEE N: <br />C,EarH@112g.t <br />FAcerTY NAME <br />G <br />PIE <br />STTEADDRESS G } <br />3tr Nuntoer <br />N <br />CeY-\�\�`\ <br />CRy / <br />STATE <br />LP <br />HOME Or K41UNG ADDRESS (D atom tram Site Address) / <br />J <br />Received By: <br />CDy <br />STAR Lr <br />PHOKE #1 aT <br />APN N <br />LAND USE AUCATION N <br />R <br />wKE / <br />�l 6:5-0 �O <br />N"a 62 <br />( of 5 <br />SOS DISTRICT <br />LOCAnON CODE <br />rnNITRArTnR / CFRVICF RF.OUESTOR <br />REQUESTOR <br />CIEarHBL""^e' S� <br />OPTED I 1 �'t`�IJ�l <br />EMPLOYEE *: <br />Busnass NAAEp <br />ASSIGNED TO: 1'�.� <br />' <br />7r; <br />EMPLOYEE N: <br />HOME or MALm ADDREsa <br />Date SerViCOCOmplabad (it aY+adYC=Wkttd): <br />FAX# <br />$ERVICECODE:D2 1 <br />PIE <br />Fee Amount: 1 5 a . �} U <br />Amount Paid <br />Payment Date nf ILL <br />CRy / <br />STATE <br />LP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorzed agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly cbargeS associated with this project <br />or activity will be biDcd to me or my business as identified on this form <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN Jv�1yyCu��.w'yf <br />COUNTY OrdinO Codes, 3larldards, STATE and FEDERAL IaWS."y <br />APPLICANTS SIGNATURE: DATE: C// / `� " (�/�/,�, C 8 qr�/ <br />PRoraRry / BustNim OwNIRWJ OPKRATOR / MANAGER ❑ OrtaR AUrnoRnZm AGENT ❑ <br />IjAp?tXwvTisnot die B&Lwg AR7T.proof ofawhoAtadonto*xisregrired Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or emvonmenial/site assessment <br />information to the SAN JoAQwN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at tate same time it is <br />provided to me or Div reoresemative. <br />TYPE DF Service REQUESTED= <br />COMMENTS: ULM PZ-t'el1'( lea, t3ect�tv�e. we c5 Qolk" Tec <br />Ct ✓� re� c Icet i } Z neem -rk rn M n wL C, <br />l Qln1� fI�IS� Gv7 <br />OPTED I 1 �'t`�IJ�l <br />EMPLOYEE *: <br />DATE <br />ASSIGNED TO: 1'�.� <br />EMPLOYEE N: <br />DATE& <br />Date SerViCOCOmplabad (it aY+adYC=Wkttd): <br />$ERVICECODE:D2 1 <br />PIE <br />Fee Amount: 1 5 a . �} U <br />Amount Paid <br />Payment Date nf ILL <br />Payment Type,1l <br />Invoice X <br />Check X <br />Received By: <br />EHD 48-02-025 SR FORM (Golden RoM <br />