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STATE Zip <br />REQUESTOR <br />pain/el M e-tey\Je -z— <br />Bu ss NAmE 1-cut ur• Lo,_ AA 6( c <br />HOW or filAluNo AoDRESs 803 es a <br />CITY -52 A Or C q 577 <br />EEO 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Goeien Rod) ce,t -r -L 4- is 3 S 2:1A r+ <br />ne_e67 SAN JOAQUIN COUNT V ENVIRONMENTAL HEALTH UniARTMENT <br />PR <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 JOAQI IN <br />COUNTY Ordinance Codes, Standards, STATE and IIDEFtm, laws. <br />SERVICE REQUEST <br />APPLICANT'S SIGNATURE: ov,--tut 30- DATE: <br />PROPERTY I BUSLNESS NF,R.EV OPERATOR I MANAGER El OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILIJNG PARTY, proof of authorization to sign is required <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 environmentaLsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IlEA1.1111)EPARTMENT as soon as it is available anLat the same time it is <br />provided to me or my representative. t'Ll Vii <br />TYPE OF SERVICE REQUESTED: '' 1 \1 e ' i VPD <br />COMMENTS: DEC n 1 <br />SAN J04 Q ui H,ENV/RoNroN COLIN Ty cAL_TH DEp ENT/AL AR ymENT <br />ACZEPTED BY: (Ye v-v---cec-, c-c <br />_ <br />EMPLOYEE #: )4 (0 7 DATE: <br />ASSOC./ED TO: 1.....-‘,‘", kx-f\-4— ElitPLOYEE #: 4 6 g9 DATE ( - <br />Data Service Service Completed (if already completed): SERVICE CODE 5,3 P I E: 160 1 <br />Fee Amount .4-(X.- Amount Pal Li.(_E: 0 O Payment Date /3...h 2.2_ ir <br />Payment Type VI 6 ,4 _ invoice I Check if / s-3 s--72_2q7 Received By: /1 <br />Title <br />Type of Business or Property <br />I\Ciz1Ik evnl <br />FACILITY DI I SERVICE REQUEST <br /> // EvO SROOg 61 2, <br />OWNER I OPERATOR <br />FAcirry <br />NA <br />rLfjo t I n <br />mi(jArsA srycipons .) _I r Mai n+cetn t-I Ewe eartwo.... <br />Mem <br />1--ka./ I-tot/3c_ q 53' 1 I <br />HOOK of MAILING ADDRESS Of DIffenrt from Site Ad(1ress) <br />CITy <br /> <br />ccf c <br />PRONE Iti J Ex-r. APN I <br />/2,4:1 <br />PRONE #2 Err. <br />) (elo 1611 <br />Street Number <br />LAND USE APRUCATioN I <br />BOS DISTRICT LocAnom Ca* <br />CONTRACTOR / SERVICE REQUESTOR <br />CHEcfc Hai <br />3 -3q33 bn <br />PHOltic <br />FAX <br />STATE <br />If Ritur4c, AcoPE ss0