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SAN JOAQUIN COUNTY ENVIIROrMENTAL REALTK D tPARTMENT <br />SERVICE "QUEST ' <br />Type of Business or Property ^ FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR CHEC!( if BILLING ADORESS12 <br />FACILITY NAMEdhwli� <br />SITE ADDRESS <br />9' tuber Direction S �Ilarte C <br />tty Zip code <br />HOME or MAILING ADDRESS (If Different from Site Adde ess) <br />53' et �i umber SUeet Name <br />CITY �j / ST, <br />QST %P <br />1 ^ <br />PHONE #i APN # LAiD USE APPLICATION # <br />t 209) �z-1p3S3 <br />PHONE #2 Exr• SC S DISTRICT L3CATION CODE <br />l 1 <br />CONTRACTOR / SERVICE REQCESTOR <br />REQUESTOR CHECK It B LUNG ADDRESS <br />PHONE # Ex -r. <br />BUSINESS NAME <br />HOME or MAILING ADDRESS FAX# <br />CITY ATE ZP <br />BILLING ACKNOWLEDGEMENT: I, the ur,dersign�d property or business ewi-er, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ErrvzR0r1N1ENe&.�_ HEALTH DEPART'm4 T h'-)urly charges associated with this project <br />or activity will be billed to me or my business as identified on tkis firm. <br />I also certify that I have prepared this application and that the w:)rk to be performed w I be done in accordance with all SAN JOA-JIL4 <br />COUNTY Ordinance Codes, Standards, S T and FEDERAL law;. / / <br />✓� <br />APPLICANT'S SIGNATURE �' DATE: / 15" &2 <br />PROPERTY/ BUSINESS OWNER LJ OPERATOR/ )4A AGER Or —OTHER AvTnoR>zED Acorn ❑ <br />If APPLICANT is not theBlLL'WG PArr proof of authorkahion to sign is •eqi. fired Title <br />AUTHORIZATION TO RELEASE INFORMATION When applicable, I, the rmser or operator of Ie property located at the <br />above site address, hereby authorize the release of any and ill results, geotecbncal rata and,'or environmental/site assessment <br />information to the SAN JoAriuIN COUNTY ENVIR9NmEN i -,L HEAiTH DEPARTMENT as soon as it is available ani at the same time it is <br />provided to me or my representative. <br />EC <br />TYPE OF SERVICE REQUESTED: Co <br />COMMENTS:] �j j�U!Zi SEP 2 til 7 <br />- o2a <br />JOA <br />iN ��NT <br />H=�LTy pE AUNT <br />ACCEPTED BY: , EMPLOYEE #: G DATE: <br />ASSIGNED TO: EMPLOYEE #: t , DAT_: <br />Date Service Completed (N already completed): SEPvr--- CO:E: L1 1 PIE: `� I C <br />Fee Amount: Amount Paid <br />OD Payment Date `? <br />Payment Type ,- - Invoice # Check # J `? �(; Received By:/ <br />' G <br />EHD 48-02-025 c o m f• A 1309-1,341 SR FORM (G31den Rod) <br />REVISED 11/17/2003 <br />