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v� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Z <br /> OWNER/OPERATOR <br /> l !{ n c Hoo. <br /> 4� CHECK If BILLING ADDRESS C� <br /> CA <br /> FACILITY N E vl vC~! i nsi ,fie o ^o <br /> t -I. IJ u o� (o ct. a i I S ((It-� <br /> SITE ADDRESS �IGrj puce- t,C rl�ke . � CIG n S26J-j- <br /> 5159 <br /> C <br /> " 59 Street Number Dlrectlon Street Name OI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 15 Z t✓u� �� <br /> Street Number SSreet Name <br /> CITY l <br /> STATEn ZIP <br /> ' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# �(J <br /> ( ) '313-S Ben <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS D <br /> i A Y)CA �c�c{►� <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> L 'Gl. (2 ) 3-73 -sem . <br /> HOME or MAILING ADDRESS FAX# <br /> US <br /> CITY C +o C, C STATE C ZIP Ct G 0-2 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business OWI)er, operator or authorized agent of same <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HI ALTIt DEPARTMENT hourly charges associated with this projeu <br /> or activity will be billed to roe er 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 JOAQUIr: <br /> COUNTY Ot-dincuu•c orales,Stawkwdc, SPATE a ted EI.DrRAL laws. <br /> APPLICANT'S SIGNATURE: ZQ��� <br /> PttureITYIBuslxt.ssOt�xt:i<I�., OPERATOR ❑ Ont A uoRtzl:n.�rt�T ❑ <br /> 11'APPLICAAT iS 1101 Ila'BILLING PARTY,proof of authoi-kation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORNIATION: When applicable. I, the owner or ope►•ator of the property located at the <br /> above site addi-ess, hereby autiorize the release of any and all results, geotechnical data and:or environmental/site assessmclt <br /> information to the SAN JonQUIN COUNTY ENVIRONMENTAL_HEAI_Tu DvAIt'rNIENT as soon as it is available ind jI the same time it i; <br /> provided to me or ill),representative. /A <br /> It At�C <br /> TYPE OF SERVICE REQUESTED: �j C p`f 1Z T C 0 t,%Z)It LTA,TI O N � <br /> COMMENTS: OR <br /> N gNJ0ROV/Vco�?1 <br /> rN p pq� � <br /> N 7- <br /> ACCEPTED BY: -1Z. C EMPLOYEE M ATE: ! <br /> Nt •- CLr~LL_otl y Dl 1,;zI <br /> ASSIGNED TO: �C t t EMPLOYEE M (� C 3 DATE: q + l ' <br /> Date Service CJompleted (If already completed): SERVICE CODE: �l I U ( PIE: U L I <br /> Fee Amount: 5 z Amount Paid J 15 .2 Payment Date q/1 G/Z I <br /> Payment Type CRS t–r Invoice# Check# 1Z� ZZ�.Z Received By: <br /> EHD 413-02-025 SR FORM(Golden Roc) <br /> REVISED 11/17/2003 <br />