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7--j 0 SAN JOAQUIN COUNTY .EI NVSRROIVMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY 11) # BUSINESS MAME / SERVICE REQUEST # Iiko 1A `moi %/o w 06(45`2-f Ll It OWN ER/OPERATOR / STATE CHECK If BILLING ADDRESS FACILITY NAME A" SITE ADDRESS / f�CJ UNIRONM ENTAL �C7 G7 � •ff � /�j�;1 O i? � ��J Ey fy SlreetNumber pi ec on 'StreeiName EMPLOYEE #: DATE: l y (/ Z— j C't Zi Code HOME or MAILING ADDRESS (if [different from Site Address) / EMPLOYEE M DATE; G' /2— f 2-4 Date Service Completed (Ifalready completed): SERVICE CODE:qf Street Number Fee Amount: Amount Paid -1 Street Name CITY j STATE zip PHONE #1 AMT• APN :# LAND UsE APPLICATION A (7101D Received By: PHONE #2 EMT. BOS DISTRICT LOCA`PION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CtI.CKifBILUNGAvDRESS 9 BUSINESS MAME / COh4MENTS; PHOMF # r �p EMT• HOME or MAILING ADDRESS..-. / FAX# CITYJam` e' (rel 4,14C 40 STATE ZIP BILLING ACKNQWLEDGGEME,NT: I, the under; acknowledgo that all site and/or project specific ENV or activity will be billed to me or my business as iden I also certify that I have prepared this application and COUNTY Ordinance Codes, Standards, STATE and FEI APPLICANT'S SIGNA'T'URE: PROP-9xTYIBUSINESSOWN>;:R❑ OPE&T It.I4IIAa If 4PPLICANT is not the BILLING PARTY, above site address, hereby authorize the release of ai infoaznation to the SAN IoAQUIN CouNTY ENVIRONMENT provided to me or nay representative. . property or business owner, operator or authorized agent of same, wrAG REAI.TH DEPARTMENT hourly charges associated with this project on this form. the work to be performed will be done iat accordance with all SAN JOAQUIN DATE, -. C� ' // JZ— L ❑ OiHmzAuTnoRiznn Acm7€ f of auflaoriza&n to sign is required Title ' When applicable, I, the owner or operator of the property located at the and all results, geotechnical data and/or eavironmental/site assessment HEALTH DEPARTMENT as soon as it is available and at the same time it is TYPE OF SERVICE REQUESTED: PA` M E PST COh4MENTS; r= I JUN 2012 1 SAN JOARUIN COUNTY UNIRONM ENTAL HEALTH DEPARTM ENT ACCEPTED BY: - EMPLOYEE #: DATE: l y (/ Z— AS SIGN EO TO: 1y� 1 l EMPLOYEE M DATE; G' /2— f 2-4 Date Service Completed (Ifalready completed): SERVICE CODE:qf P! E: _¢{ -3 c-, Fee Amount: Amount Paid -1 Payment Date/ .i Paymen#Type r. htVolce # Check # �/� t 1 Received By: EHD 48-02-025 REVISED 1111712003 SR FORM (Golden Rod)