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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP IMECV L __ n <br /> SERVICE REQUEST ,., <br /> Type of Business or Property FACILITe)IDY ID# SERVICE REQUEST A <br /> SAN�w�N JET► o . <br /> OWNER I OPERATOR <br /> J� (�(���1 CHECK if BILLING ADORESSO <br /> FACIIRY NAME ,SIJ C K✓O U v <br /> SITE ADDRESS '�0 GQ� RCE /1 MAN-ryc2 85336 <br /> Sr treet Number Directs n Street Name 1 C1W Z,V C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) j-T'�O��71 Lri 7)C— <br /> street <br /> Name <br /> CITY S Gtr )11 71}L� STATE <br /> CA <br /> ZIP C1_5 - <br /> PHONE#I E— APN# LAND USE APPLICATION# <br /> aC <br /> t2�) Si 5—g3g8 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> tL�s 1733- V4 1 Yt._ <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSPIESS NAME V + e PHONE# Ex' <br /> HOME Or MAILING ADDRESS l4 p Co�rY1'YY1eYa° Au-e #. 13 d FAX# <br /> CfTYM Te STATE GA ' zip q r73 <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 ENVIRONSIF.NTAL HEALTH DGPARTMF.NT 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 FEDERALJlaa/ws. <br /> `�/ C�i ) <br /> APPLICANT'S SIGNATURE: � l//1ij DATE: S l 1 Z 3 <br /> PROPERTY/BUSINESS OWNERIO OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT❑ <br /> 1f APPLICANT is not the B1111NG PARTY proof ofoulhorizatio n 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 environme / i e <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT'as Soon as it is available and <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 9' <br /> CowrENrs: Q�Gn o/��/u <br /> SAN JOAQUIN COU TY <br /> ENVIRONMENT <br /> HEALTH DEPARTM T <br /> ACCEPTED BY: EMPLOYEE M DATE: 4)� f� <br /> 2;1 -� <br /> ASSIGNED TO: EMPLOYEE M DATE: 2, <br /> Date Service Comple d (if already completed): SERVICE CODE: to 6 1Pi : D <br /> Fee Amount: It Amount Paid Payment Date 2 <br /> Payment Type r i Invoice# Check# Received By: <br /> EHD 48-02.025 S FORM(Golden Rod) <br /> REVISED 11117/2003 1 ljMol1 <br /> Cbl <br /> 9 <br />