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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE;QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WiNFf2 �T SS 30Z <br /> OWNER/OPERATOR • , <br /> �IN� S S CHECK if BILLING ADDRESS <br /> (-A'T1ON <br /> FACaHY NAME <br /> lND Dat/a jn//rV EIZ <br /> SITE ADDRESS AcArn PO MV190/r7 <br /> Street Number Direction Street Name Cil ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PO • BD 1a Street Number Street Name <br /> CIN STATE LA ZIP / 5o2�g <br /> WUOD62/D c <br /> PH0NE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) 36 a - s8 4wo- ?7114r, d <br /> PHONIER EM. BOS DISTRICT LOCATION CO E <br /> ( ) Ct <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> O £Sn/E <br /> BUSINESS NAME /1/)r5N£ PHONE# ExT. <br /> C Nlu� r�i✓ J <br /> HOME or MAILING ADDRESS FAx# <br /> y( 7 ) Z <br /> CITY STATE C ZIP <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 to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STand FED L laws. 9 <br /> APPLICANT'S SIGNATURE: 1 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ ATHER AUTHORIZED AGENT IGS <br /> IfAPPLLCANT 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: N1 T I 0AD11,16 5VIIS5;T-(.Ar <br /> T D E % <br /> COMMENTS: /Sj RECEIVED <br /> SEP - 3 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: O L I EMPLOYEE#: 3 y A : ct 3 ail� <br /> ASSIGNED TO: P"'/e,6 r N A- EMPLOYEE#: S3 L DATE. 3 06 <br /> Date Service Completed (if already completed): SERVICE CODE: s 2 5 P I E: <br /> Fee Amount: 5-?- •- O O Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> \ REVISED 11/17/2003 <br />