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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIL"ID# SERVICE REQUEST# <br /> 9 <br /> OWNER I OPERATOR r <br /> Ang6G , CN BILLING1ew) ' Oa V tS LL<rrB > CHECK if BILLING ADDRESS <br /> FACILITY NAME lJ <br /> Sc�l,t.efZe Burr TrA&y <br /> SrTE ADDRESS 2-14- N R� ire� Cj -3� <br /> Street Number Dlrectior Svsat Name C D Cods <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> o't` Street Number Steel Name <br /> Cm STATE zip <br /> —\,r Cd g9376 <br /> PHONE#1 EYT APN N LAND USE APPLICATION# <br /> t �s33 -�9'q 21-L-2qv-ofro-o <br /> PHONE#1 ErT• BOS DISTRICT LOCATION CODE <br /> t ) Bob 41',O-Ct I L`�5+-� 5 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> Civ CHECK if BUNG ADDRESS <br /> BUSINESS NAMEPHONE#0� aQ LJ—C— �• <br /> (q l$ gs2- b <br /> HOME or MAILING ADDRESS FAx# <br /> �y 2 E 4AV Wa l&k 4VC ( ) <br /> CITY rat,y A zip 2S'3?6 <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 /> 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 /> CotINTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Aub .,R a DATE: <br /> PROPERTY/BUSINESS OWNER GEOPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT❑ <br /> 1f APPLICA.vT is not the BILLING PARTY,proof of authorization to sign is required Tine <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, the owner or operator of the property I at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUs' <br /> information to the SAN 1OAQUtN COUNTY EN iRoNMENTAL I11ALTH DEPARTMENT as soon as it is available and at the ���• <br /> provided to me or my representative. n O <br /> TYPE OF SERVICE REQUESTED: f1 QMH 011� <br /> COMMExrs: Fq T/R p�/N <br /> Np AgRToON y <br /> MFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: e EMPLOYEE#: DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: 1 PIE: l 2 <br /> Fee Amount: 2 Amount Pal �S� ��� Payment Date <br /> Payment Type ,l Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />