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SAN JOAQU14WTY ENVIRONMENTAL HEALTH RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GNS 5'1A 109-E- CoQ -A464- <br /> OWNER/ <br /> -OWNER/OPERATOR E-0-170 R ISE L 1. ` — c, <br /> V A M �>JA I� V V��A Tu� CHECK IfBILUNGADDRESS <br /> I� <br /> FACILITY NAME NK <br /> C-0 <br /> 0/ A m p M <br /> SITE ADDRESS I I()Q S . MA04 ST(LEC T MMSTEC A q5 3 3 �- <br /> Street Number I Direction I Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ((�� �/n/� _n <br /> 11�E L I A e LE 1 E ( 1,10`E J M CHECK if BILLING ADDRESS <br /> BUSINESS NAME v 1 PHONE# EXT. <br /> 5'2- t AtA010C, I(ZaN ST 2- 4S <br /> HOME or MAILING ADDRESS FAX# <br /> (2cei) 4S — y- 9 S 3 <br /> CITY 011 Y--DA <br /> L E STATE C A ZIP C15-315-1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTI"/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. p <br /> TYPE OF SERVICE REQUESTED: v S 1 KUT R–O FIT EIVED <br /> COMMENTS: L OL i S.T AST JAN 2 <br /> � � �V� � v ra tZ�>✓ 1 2009 <br /> SAN IOLINTY <br /> ENV RONIMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 2 <br /> Fee Amount: Amount Paid3 S Z> Payment Date (4t <br /> Payment Type ti Invoice# Check# a f° Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />