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SAN JOAQUIN COUNTYENVIRONMENTALtoA-Uln <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L �pC 1) sl 3 j � 3 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> /<v L 7/ r S 4-H 114 AnIGA T <br /> FACIIrrY NAME C xrX tf—S 9 ,�/I A .d`I�ri l�F' <br /> SITE ADDRESS yl 6 C'�j(_,l 7-;/� � �lq ' 4/ <br /> Street Number Direction Street Name C Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 �L-1 L"— 7 Street Number Street Nam C� G <br /> CITY 4 ' n / <br /> C A .STATE ?,, 6 G <br /> PHONE#1 Y Err' APN# LAND USE APPLICATION# <br /> •Z -Sy <br /> -fir 7� 2t �1 - 3s6-23 <br /> PHONE#2 yoI Ess. �b �l BOS DISTRICT LDCAnD CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# Exr' <br /> HOME or MAILING ADDRESS FAX# <br /> t ) <br /> CRY STATE ZIP <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 or <br /> 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 JoAQUN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: <br /> /� ,l Ci c Iva",6� DATE: <br /> PROPERTY/BUSINESS OWNER 14 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire <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: p " F—i4G1 L_t p4l,A-n.1 <br /> COMMENTS: PAY <br /> RECEIVED <br /> OCT 11 2007 <br /> SAN JOAQUIN RONMENTAL <br /> ACCEPTED BY: EMPLOYEE M •H <br /> ASSIGNED TO: r-4-.44 t a-g Z EMPLOYEE#: U� DATE: I D rr d <br /> Date Service Completed (if already Completed): SERVICE CODE: 6-2.2 PIE: [(lot <br /> Fee Amount: t�_ryy Amount Paid Payment Date <br /> Payment Type invoice# Check# Received By: <br /> EHD 40-02-025 _SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />