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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK R BILLING ADDRESS O <br /> GoRgaPAssi FA.aMK /t1/G. <br /> FACILITY NAME <br /> SnEADDRESS 13&V (.tJ. V.VWl�21066 A'A44 ��' 2 <br /> Street Number DlneOon Street Name C' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Sue Address) 11292 /II. ffLPrNE <br /> Street Number Street Name <br /> CITY ' STATE 64 ZIP '75-212. <br /> PHONE#I t•H✓ EXT. APN# LAND USE APPLICATION <br /> 2 <br /> Dll-o30- # I <br /> (Z01 ) 94B -077 /s 4 <br /> PHONE#2 EKT. BOS DISTRICT LOCATION CODE <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Af X5 PY CHECK N BILLING ADDRESS <br /> 3 -bG <br /> BUSINESS NAME l-V d PHONE# FM <br /> p/t1oAI /Nu•cPHY 13 <br /> HOME or MAILING ADDRESS <br /> Cm L040 STATE (yq _ Zip qs7¢ <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 /> 1 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 /> PROPERTY/BusmEss OWNER OPERATOR/MANAGER 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 /> 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: <br /> COMMENTS: /b RECEIVED <br /> 11�- L71i/ir» �2�1 `�1 DEC ^ 0 2011 <br /> SANJOA�,IN COUNTY <br /> { ElPARGNtAENr4L <br /> Hol THD rv\RTVENT <br /> ACCEPTED BY: fff EMPLOYEE#: DATE: / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 5-kf IPIE: <br /> -111 <br /> Fee Amount: ! Amount Paid �O " Payment Date 2 <br /> Payment Type G Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM olden Rod) <br /> REVISED 11/1712003 <br />