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Or IN .rU. VU11N %—IJU1N1 Y L'1NV1KU1N1V1EN1ALIYEALI11 0EPAK11V1ENt <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�ov�.g3 `73 <br /> OWNER/OPERATO <br /> dl E12 J CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 3523 W 5C)NC,rwx4 Aue SToclKTvN ci15ZOLI <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 'V T� At'k <br /> CITY STATE ZIP <br /> Tvtn 01 A qZoll <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2�) 610"40-37 / 0 <br /> q OFd i3 ;-q <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> (204 ) Mari^ (, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS <br /> �2i ob�tzk E . JIA�Ivcic <br /> BUSINESS NAME PHONE# Ex . <br /> Zo 1 O-14 01,-7 <br /> HOME Or MAILING ADDRESS FAX# <br /> DZ A(nC14E5-(--a A ( ) <br /> CITY ';Tc)e-y-ry vN STATE /4 A ZIP <br /> llR qSZb,} <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 tat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE ORAL 1 <br /> APPLICANT'S SIGNAT R :- DATE: —I ^Z6-2,C0l. <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANA ER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 /> inforination 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: <br /> COMMENTS: SEP 2 8 2006 <br /> SAN JOAQUIN COUNTY <br /> / ENVIRONMENTAL <br /> W.WH DEPARTMENT <br /> ACCEPTED BY EMPLOYEE#: Y/1? <br /> DATE: <br /> ASSIGNED TO: ,r /�„ EMPLOYEE#: s��/C DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 � PIE. 3 <br /> Fee Amount: (, L Amount Paid I O Payment Date <br /> Payment Type Invoice# Check# Z J a 3 eceived y: <br /> EHO 48-02-025 R FORM(Golden Rod) ' <br /> REVISED 11/17/2003 <br />