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5AN �10AQUIN COUNTY FNVIRbNMENTi`AL HEALTH DEPARTMENT <br />SERVICE REQUEST - <br />FACILITY ID # SE I -- <br />REQUEST # <br />Type of Business or Property 3 ��,.� ewJ �� <br />(.moi ..{� <br />OWNER /OPERATOR CHECK if BJ,&,kNG AD13RE8913 <br />,:r <br />FACILITY NAME <br />SITE ADDRESS �'% <br />- _ e ,..— .. 7�. yin Cod* <br />�.� / % <br />HOME or MAILINQ ADDRESS (If Different from Site Addres9) <br />CITY <br />QO 03 Xff <br />PwoNE V <br />REQUESTOR <br />BUSINESS NAME: <br />HOME or <br />APN # <br />LoV---(ov -�� <br />EXT. <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />PHONE # <br />LOCATION CODE <br />CHECK If 81LLI G DDRES 13 <br />/ - �- " <br />CITY -- -- r- _ STA1E ZIP t [d <br />BILL)<NG 1C i�OWI�G :E�d I. the undersigned property or business owner, operator or authoriZed agent of same, <br />acknowledge that All Site and/or project Specific ENVIRONMENTAL 1-lrALTi4 DcPARTMENT hOUrly charges associated with this project <br />Of aetivity will be billed to me or my business as idcntiflod on this Form. <br />I also certify that T have prepared this application and that the work to be performed will be done in accordance with ali SAN .IOAQUIN <br />COUNTY OYdlnance Ccules, Srandardi, STATL and FEDERAL laws. <br />APPLICANT'$ SIGNATIME: _ _- DATE: — <br />PROPERTY / BUSINrSs OWN ER 13 Oer xrols / IVIANAC+vt 0 OTHrR AUTHURI7,.FD Ae>iN'r �f �_,�J�A„ �✓_ _ i <br />IfAPPI,[CANT is not the BILLl LRTY proof O/' authorization to sign is require <br />AUTHORIZATSON TO RELEASE INI3,?RMATION: 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, geotcchnical data And/or environmentaVsite assessment <br />information to the SAN JOAQUIN COUNTY I"NVIRONNIENTAL HEALTH DEPARTMENT 1,9 Soon as it is available and at the same time it is <br />:_t..a . nretwn <br />TYPE OF SERvicE REQUESTED: �( ST ��-C) � t -T-- <br />COMMENTS: ,` <br />ACCEPTED BY: O (` ( t/E i ►�-Y-C <br />ASSIGNED To: CA c-" 17 - <br />Date Service Completed lif already completed): <br />Fee Amount S� _ Atnount Paid '3 <br />Payment Type Invoice # <br />EMPLOYEE #: C z— <br />EMPLOYEE: 2 <br />SERVICE CODE: <br />P� 17-s— Payment Date <br />Check # �+��� 6 <br />1AW / ( f3 <br />DATE: 0 <br />P1 .2 30e' <br />Recelved By: <br />EHO 48-07.025 k14 ti S�7© SR FORM (Golden Rod) <br />REVISED 1111712003 <br />