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SAN JOAQCOUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L C, A S D L l ti�I= --F � � 7 q SGL G%o <br /> OWNER/OPERATOR <br /> C 0 4 0 C O CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS T 0 2 N-t-o 14 ' _ S T-0 G V-t-0 <br /> / �9 ,57201p <br /> 0 0 6 Street Number I Direction Street Name citv Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)( <br /> I- `" R'O Wr-- Street Number Street Name <br /> CITY STATE ZIP <br /> S G R Ik VI^E-- C A. <br /> PN# LAND USE APPLICATION# <br /> C1 PHONE#1 EXT. <br /> q <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ^4 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> jMIcWA-rzL �AL"r0r( <br /> BUSINESS NAME PHONE# EXT. <br /> A (.-rOr-( C - q(6 `3�3 -1r rL <br /> HOME or MAILING ADDRESS FAX# <br /> P - 0 - 807( / OZS'-- ( 916 ) "3 :�3 - 1(� Z <br /> CITY S T Arm R A, lA g-. ' STATE CA <br /> zip GS--b R I <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:: !l 6 lf" A � <br /> z— - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ed C 0"T"2 A-tfiD rL <br /> If APPLICANT is not the BILLING PARTY,proof of 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �L A-l.( t/t &AAJ <br /> COMMENTS: RECEIVED <br /> DEC 5 2005 <br /> SAN JOAQUIN COUNTY <br /> FNT <br /> VIROMENT <br /> m TH DEPARTMENT <br /> ACCEPTED BY: ('iL l l"; i? EMPLOYEE#: <br /> ASSIGNED TO: �{fj / n _ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I C` l,, P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: '. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />