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"�' ��c `-'=`• �\/ul•11 A:11I r1nv1'11r1.C1'4lAl .11EAL1t11JE.YAK 11V1E+'1V•I' <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />79' <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESSE] <br />FACILITY NAME •� <br />SITE ADDRESS I L174- <br />Street NumID on <br />HOME or MAILING ADDRESS (If Different from Site Address) Street Name Ci Zi Code <br />------ -- - acreec name <br />CITY STATE ZIP <br />PHONE #1 �T• APN #LAND USE APPLICATION # <br />PHONE #2 ExT. BOS DISTRICT LOCATION CODE <br />( ) <br />CONTRACTOR / SF,RVTr'r. 'P_F"TTVQ rnn <br />++=-a.ai.v r��-ialw rr 1,L' 1�C71b1Y11�,1V 1: 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 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, St ards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: l <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER 0. OTHER UTHORIZED AGEN� <br />(}APPLICANT is not the BILLING PARTY proof of authorization to sign is requi ofd 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 />ffTYPESERVICE REQUESTED:PAYMENT <br />: <br />oCi 14 2009 <br />- �OAOUIN COUNN <br />SANEN�RONMEMWENT <br />HEATM DEPAR <br />ACCEPTED BY: { t1 '� O <br />�GrL �/,� C l�� EMPLOYEE #: DATE" <br />AssIGNEDTO: kn j EMPLOYEE #: S& tl2__ DATE: a O <br />Date Service Completed (if (ready completed): SERVICE CODE: P i E: Payment Date _30&0� <br />Fee Amount: 3 ©� Amount Paid 'L� <br />s, D t7 (� <br />Payment Type Invoice # Check # 5 Received By: <br />EHD 48-02-025 <br />•-_ <br />REVISED 11/17/2003 :,SIS 1=0RNt <br />