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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 th Vie work to be perform will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standards, ST an*FEDk4/ws.
<br />ICANT'S SIGNATURE:
<br />TY / BUSINESS °WINE**,
<br />If APPLICANT is not the BILLING PARTY, proof if authorization 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 environmental/site assessment
<br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is
<br />OPERATOR / MANAGER
<br /> DATE:
<br />OTHER AUTHORIZED AGENT 0 0 14," Ai
<br />SAN JOAQUI. OUNTY ENVIRONMENTAL HEALTH 'ARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />s-\ 'PP K-1;144 e iNdi Co P4 Pi,.4,7,V,
<br />FACILITY ID #(1)
<br />/ /X
<br />_ SERVICE REQUEST # ,...,
<br />-2, / 7 3
<br />TImItireiRESSE1
<br />OWNER / OPERATOR
<br />A he-1,--6- (;) e re- R.Dritri- _ / FACILITY NAME A ,,- Noii,--k-41E-44 PAA IQ OR-
<br />SITE ADDRESS
<br />-3 60 Street Number I Direction I N ID YrCI")2i 6Eat-I0T -6 b e vg ,., A Ailkit4TE. 411 ci534
<br />Zip Code
<br />HOME Or MAILING ADDRESS Of Different from Site Address)
<br />al 0 0 Street Number c:,3 fA ic- betani,et e V-6.
<br />CITY.: -Ki-AL, CA
<br />STATE
<br /> LI f
<br />ZIP
<br />
<br />PHONE #I
<br />2°4) 4 8‘
<br />APN * LAND USE APPLICATION #
<br />PHONE #2 E.
<br />)
<br /> 1a
<br />B 0 S DISTRICT Loc% N CODE i
<br />NTRACTOR / SERVICE RE UESTOR
<br />REQUESTOR CHECK if BILLING ADDRESS
<br />BUSINESS NAPAE PHONE #
<br />( )
<br />EXT.
<br />HOME or MAIUNG ADDRESS FAx #
<br />( 1
<br />CITY STATE ZiP
<br />rovided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: O c
<br />COMMENTS: spoT pgetor\I 4,vcils, c....„,sgs, 1\Jc ,, Ta,A,,,e,,,,,., .-rit_t. Dt otArzerp6
<br />Srrof 1 Ie.& `41 ,N, yiA" koti-r16") it 146,oi 4AA)0 9.;4 I LS Cev-&._ Ak- I iNr<Ti^t D
<br />co. Kv-vk i evz., vy in) -1-4.14 V 6,33, Ac-r;
<br />ACCEPTED EY: cc c ( EMPLOYEE #: -21 DATE: (1,726/r 0
<br />ASSIGNED TO: 11)-2_1•0 /1--A -#.1-. EMPLOYEE #: 2 L.2 DATE: i) / -0
<br />Date Service Completed (if already completed): SERVICE CODE: 5 2 _2___ P E:r - 2 ,t.) 2 _
<br />Fee Amount: 4 z 3T th.) Amount Paid -t ....,3 0 . 0 -D Payment Date L pc 8 --c,
<br />Payment Type Invoice # Check # 31? ,..?"'. Received By:
<br />EHD 48-02-025
<br /> SR FORM (Golden Rod)
<br />REVISED 11/17/2003
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