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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D11 PARTMENT <br /> SERVICE REQUEST _ <br /> FACILITY ID# SERVICE REQUEST# <br /> rTyr of Business or Property 5(210o �2 <br /> NER 1PERATOR r L! �!J CHECK If BILLING. G ADDRESS� <br /> a o2�PA-PT PA1Z�� , I <br /> ILITY NAME I , P, o I! tl L ! r '// <br /> ,�� Lv.C.i <br /> EADDRE v ?�I /�✓@ �P Cit Zip Code <br /> Street Number Direction Street Name /� <br /> )ME or MAILING ADDRESS (If Different from Site Address) f I--1 -Z- /,. A I I poN-e, <br /> I Street Number Street Name <br /> STATE (f <br /> A Zip Q Z(fir <br /> ;TTY '1 <br /> EXT. AP <br /> / �j LAND USE APPLICATION# <br /> SH <br /> ONE#1 063— //01) <br /> � ) <br /> Exr. BO5 DISTRICT LOCATION CODE'` <br /> PHONE#2 "r <br /> ( �? 2- CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �J CHECK If BILLING ADDRES 00 <br /> ///t P1 /�. D�Ul @/� PHg�E+ Ezr. <br /> BUSINESS NAME A/' f� t/r 2L(�/.l.0r► II^ l TcF.j�G/�►'�Pl �'' '!� �6 <br /> N-11/ FAx# Q [� <br /> HOME Or M LING ADDR S 3 <br /> � fes' ZIP <br /> CITY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> acknowledge that all site and/or project <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 erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S ATE and FEDE 1 S. <br /> APPLICANT'S SIGNATURE: DATE' <br /> PROPERTY I BUSINESS OWNER P R I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br /> 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 HEAL'T'H DEPARTMENT as soon as it is available and at the same time it is <br /> provided to r::e Cr n:y repr'-sent2t v_. ,Q E <br /> TYPE QF SERVICE REQUES7ED: �Qu f L'�� ������ <br /> COMMENTS: r� > =Q S�! G t v I 'V0V 2 2 2005 <br /> /Z//`f tICILJ SAIYN OAQUINCO <br /> i I V L r`'� -LC !� - ✓J f�1A�I5 !?�Llc[ 1� d I . E� \ H�ONM,NTUNN <br /> /�- <br /> ` <br /> EMPLOYEE#: j� DATE: C <br /> ACCEPTED BY: © !✓ tJrL{ <br /> EMPLOYEE#: Sz L{ ( DATE: <br /> ASSIGNED TO: +-5[ O <br /> SERVICE CODE P1E: �Z_p <br /> Date Service Completed (if already completed): <br /> ��2. � <br /> Amount Paid Ampp rr Payment Date \\ Z 2 OS <br /> Fee Amount: 1�(�^pts <br /> Payment Type ✓ Invoice# Check# ���{Z to <br /> Received By: � [s <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />