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i <br /> SAN JOAQUIN ANTY ENVIRONMENTAL HEALTH DORTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 7/ 6,' <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME -`, Z6652, <br /> SITE ADDRESS _ 95-z 6-? <br /> -4I1Z f Street Number I Direction slxw—Lstreet Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C)—,?,O —I,� Street Number S et Name <br /> CISTATE ZIP <br /> PHONE#1 ExT• APN# LAND USE A LICATION# <br /> (114 ) 6-74 <br /> PHONE#2 ExT• BOS D TRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQVtSTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME AV�G N PHONE# EXT' <br /> •cT63 <br /> HOME or MAILING ADDRESSl FAX# <br /> ZS9�k o N E rte A , Z (CM ) 4102 ��Z.lo <br /> CITY STATE Go, ZIP Q Z/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned prope or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENv[RONMENTA HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on t s form. <br /> I also certify that I have prepared this application and that th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERA aws. Q <br /> APPLICANT'S SIGNATURE: • 11 DATE: e <br /> � ke>1 kt' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT E I.41"064W- J <br /> If APPLICANT is not the BILLING P TY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the elease of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUN NVIRONMENTAL 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: 4ZTW--d r (-T— <br /> COMMENTS: <br /> AU <br /> 'T—COMMENTS: Ail 6 LU Id <br /> d 2Q�o <br /> ENVHuMVItly"MOLA NUN <br /> PERMIT/SE YIC °''1NO <br /> E <br /> Er1V1IR PpRTME <br /> ACCEPTED BY: O Ll v E L 12A EMPLOYEE M v3 DATE: 3� <br /> ASSIGNED TO: EMPLOYEE#: T(Q�6 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I qP 1 E: 0f,- <br /> Fee Amount: 3(o , G/0 Amount Paid ?J Payment Date $ 3 0 1 O <br /> Payment Type i S Invoice# Check# 3 3 8 34 $.06 1 Received By: <br /> W 13b5 — Zt. <br /> EHD 48-02-025 SR FORM(Golde d) <br /> REVISED 11/17/2003 366�0 D / <br />