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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT R /� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME , 1� <br /> SITE ADDRESS ']I.-�C) S �Gt� <br /> Street Number Dlrection Street Name Cit ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 23O �� Gt01n I Street Number Street Name <br /> CITY C STATE ZIP <br /> JTOCh n 0/52OA9 <br /> PHONEY EXT. APN# LAND USE APPLICATION# <br /> (-5 M) 3(.3 2-a67- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> duarm S T CHECK if BILLING ADDRESS <br /> BUSINESS NAME " ` PHONE# EXT. <br /> vJ Yi I l akisAire, S rtv+ I sio 3 2-7 .6Z <br /> HOME Or MAILING ADDRESS FAX# <br /> 2 � vid l ) <br /> CITY S J TTa _j oex STATE CA ZIP Q 6-),6-),66 <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 /> PLICANT'SSIGNATURE:So C/1.7nci I /LDZGI ' DATEI, <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1 <br /> If APPLICANT is not the BILLING PARTY proof of authorization 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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: a. Auo'� P <br /> COMMENTS: Re 'W"Itw <br /> s ?o <br /> FHJD'gQU/N 2I <br /> HE9(HRONLfFCOUNIY <br /> ACCEPTED BY: EMPLOYEE#: 00'Z'-L DATE: <br /> ASSIGNED TO: ` EMPLOYEE#: C\�j3Z_ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: GjZ P1 E: o <br /> Fee Amount: ( 5 Amount Paid Payment Date 1� <br /> a <br /> Payment Type Invoice# 12—CM Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V 0 - 5-LA-7 <br /> hal <br />