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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />CFAVif F RF.QITRST <br />Type Of Business or Property v V <br />FACILITY ID # <br />SERVICE REQu T # <br />qAl , <br />/ <br />i Z Z�j (a <br />PHONE# P" <br />�9S °>u 3 <br />OWNER/ PE TO <br />CHECK If BIWNG ADDRESS <br />FACILnY NAME <br />vr'f'l�O N <br />r <br />SHE ADDRESS <br />HEgLTyOFp <br />RNfI, <br />I�r <br />V'�µ5ua1 umb.r <br />olnmm� <br />ew•rN me <br />ell <br />II coo. <br />HOME or MAILING ADDRESS (R D rent from Address) <br />��+ <br />EMPLOYEE #: <br />/Site <br />ID b Lf l/L� <br />SVwr Number <br />EMPLOYEE#: <br />r rNem <br />CnY JO <br />s <br />TE Z1 Z� <br />PHDc�1(�#1E.. <br />APN 0 <br />S` <br />LAND USE APPLICATION # <br />PHONE #2 <br />805 DISTRICT <br />LOCATION CODE <br />� 1w 14 A n�"D / crovlt-F lQVnITF.STOR <br />--- <br />REOUESTOR 1/,t , �L ,r _ L��/� <br />(•�'LyI• <br />CHECK ifI ILLINGADDRESS❑ <br />BUSINEsSNAMEV <br />1W DE�11f S Torn Ca,L,�Y . rrJ�- <br />PHONE# P" <br />�9S °>u 3 <br />HOME Or MAILING ADDRESS <br />FA%# <br />CITY Wgtylly-7 <br />STATECaf— Z�S% <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owneq operator Or auumnacV Rgv..r ,.4 <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIi DITARTMENT 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 d tha e Wo to be performed will be done in accordance with all SAN JOAQum <br />COUNTY Ordinance Codes, Standar , STA d FE laws. {� <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSLN•FSS O"IT.RO OPERATOR / MANAGER ❑ OTHER ALTNOmrFD AGENTT 48� •YYwrw�j/� <br />IfAPPUCANT is not the BIL LING PARTY proofofaurhorization to sign isrequired Titts <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property to ted at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site <br />information to the SAN JO.AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the seal <br />provided to me or my representative. <br />EHD 48-02-025 <br />SR FORM (Golden Rod <br />fI <br />TYPEOFSERVICEREQuESTEO: -[Cts. C <br />G` <br />COMMENTS: (L� EC'{1-(�l:L <br />SqE 'J AQU/ IV <br />HEgLTyOFp <br />RNfI, <br />c ACSC <br />EMPLOYEE #: <br />DATE: I - <br />�- ` LIX <br />USe"Ice <br />EMPLOYEE#: <br />DATE: L _ <br />ompleted (If already completed . <br />SERVICE CODE: S <br />PIE: <br />u� �� Amount Pal <br />Payment Date <br />S` <br />Payment Type <br />Invoice# <br />Check# Z -4—. <br />Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod <br />fI <br />