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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHLEPAktIivrcIv1 <br /> SERVICE REQUEST - <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> rh ee S <br /> FACILITY NAME If <br /> SITE ADDRESGC) �y g3) �/ j /a'• !�alnd�'- 6'mtie �{?�ryfA1 JP�¢� <br /> StreeliQu tuber DireEtion Street Name Ci Zip Code <br /> HOME Or MAILING (If Different from Site Address) <br /> ag I( O 6 A/ • Street Number Street Name / ,[ <br /> CIN /'_a/t STATS ZIP q SG <br /> PHONE#1 (7 EXT. APN# LAND USE APPLICATION# <br /> Ido ) 3 � —f 7 5 (o bol- z a <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IG' CHECK if BILLING ADDRESS <br /> �j/�7� <br /> BUSINESS NAME PHONE# <br /> G �`L /� (/` <br /> HOME or MAILING ADDRESS �j FAY# <br /> 5 35S S/arigv. I ( ) <br /> CITY { STATE ZIP C?- <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 ' <br /> o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards�d FE laws <br /> APPLICANT'S SIGNATURE: DATE: 14�1 lyazeS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof df 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. �'[ fj <br /> TYPE OF SERVICE REQUESTED: c--11Ee el 50 6• sa,( t�:&t GES MEN' <br /> COMRENTS: 0 0s- 3S ENT /O� REC <br /> F <br /> o r REC IVED SOT 10 <br /> 2005 <br /> •1 �Sz _ <br /> AN ,ApNME OUNT'/ <br /> ACCEPTED BY: SAENViRONME—COA� PLOYEE#: ;i O DATE: /O .L� �✓" <br /> ASSIGNED TO: H EMPLOYEE#: /) DATE:` J <br /> L. 61 1 <br /> Date Service Completed (if already completed): SERVICE CODE: dZ P 1 E: <br /> Fee Amount: ,37a, Amount Paid 1 g�, Payment Date 10 � OS <br /> Payment Type Invoice# Check# q I, S Received By. N G <br /> EHD 48-02-025 po -iv I �• C� � �'ri(g..m TOSS O CJ4pewt lCT . -Y /SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />