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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMkNTRR <br /> Y } <br /> SERVICT', RIQt,-2 ST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ;3.73 <br /> OWNER/O ERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILIN NAME I <br /> SITE ADDRESS 7 70J' /)?d e IZ i'i 5JrU� , 3 fLc6 w . 15212 <br /> Street Number Direction / �J f Street Name C' Zip Code <br /> HomE or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY I <br /> ZA STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ' CHECK If BILLING ADDRESS <br /> BUSINESS NAMEExr <br /> Pn) 7 <br /> HOME or MAILING ADDRESS ^ C FAX# <br /> 2 , (a f) -16)1 - Co 4-`Z- <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> a&nowiedge 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: _,. 1 ` y-t �l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT—\ <br /> If APPLICANT 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: -� % ETr' �-T pAYMENT <br /> COMMENTS: R <br /> JUN 15 2011 <br /> SAENV <br /> ENVIRONMENTAL <br /> TM <br /> MEN AL <br /> HEALTH DEPARnAENT <br /> ACCEPTED BY: /� � EMPLOYEE#: !1 DATE: <br /> ASSIGNED TO: �, _ EMPLOYEE#: t (�.� DATE' fi j <br /> Date Service Completed (if already completed): SERVICE CODE: i cf <br /> Fee Amount: Amount Paid _ Payment Date <br /> � b , <br /> Payment Type Invoice# Check# (o Received By. <br /> EHD 48-02-025 Y SR 17M X(Qddpn Rod) 5 <br /> REVISED 11/17/2003 <br />