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SAN JOAQUI' LINTY ENVIRONMENTAL HEAL Ti PARTMENT SERVICEQUEST Type of Business or Property FACILITY ID # Fft Dm 14SPI (P SERVICE REQUEST # OWNER/ OPERATOR I CHECK if BILLING ADDRESS FACILITY NAME EXT. cy ao 7 5y (IIS7-4U SITE ADDRESS ��R��city Stre t Number Direction Street ame Zip Code ROME or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ` ExT' ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE 0 I, the undersigned property or business owner, operator or authorized agent of same, acKnowieage mat an site auwut ptvio,.t specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 9 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 COUNTY Ordinance Codes, Standards, S d FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title SE ATION: When 1, the owner or erator of the property ted at the bove site address, herrebyZATION TO a authorize a the®eellea a of any and allpresults,, geotechnical datapand/or vironmentaU to assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:TTE CHECK If BILLING ADDRESS COMMENTS: �' ZI 101; I 5 4)t ., FACE -ZG -7- m.- +.. Z.69-- i PNOfNE# v! EXT. cy ao 7 5y (IIS7-4U '" 2005 c `# ).�'6 176 SAN JOAQUIN COUN STATE GJ4 ZIP 4717&!5 7&!5 I, the undersigned property or business owner, operator or authorized agent of same, acKnowieage mat an site auwut ptvio,.t specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 9 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 COUNTY Ordinance Codes, Standards, S d FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title SE ATION: When 1, the owner or erator of the property ted at the bove site address, herrebyZATION TO a authorize a the®eellea a of any and allpresults,, geotechnical datapand/or vironmentaU to assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:TTE COMMENTS: �' ZI 101; I 5 4)t ., FACE -ZG -7- m.- +.. Z.69-- i 90 - I f=oCc✓ _ ;* '" 2005 i$uTY t7 ha C- t, c a SAN JOAQUIN COUN a t'(3u �'`s ENVIRONMENTAL HEALTH DEPARTMENT ems— b" `L ACCEPTED BY: �� EMPLOYEE M DATE: ASSIGNED TO:V V `G EMPLOYEE M DATE. Date Service Completed (if already completed): SERVICE CODE: e3(x-) P I E: 4(40-7 Fee Amount.:�� t , Q 0 Amount Paid 9 Payment Date Payment Type Invoice # Check #a Receiv d By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003