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• SAN JOAQUINi OUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ',q6 SERVICE REQUEST# <br /> g!al <br /> OWNER/OPERATOR <br /> S _/ !�/Du�eQ/.N/C�ImGo/LiL/f s�)41© If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITEADDRESS /V L'///�' /(� Q//✓7 //—�i�/i✓t� G l�D / t!i9 9 5 y� <br /> /7 7 v O Street Number I DirCe�ction Street Name city Zip Code <br /> HOME or MAILING ADDRESS/(If Different from Site Address) l7�ZE� 70,-V ,-f 6r <br /> ` O Street Number Street Name <br /> CITY �Jzle/-O^/ STATE e Q ZIP p aJ a <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# / c� <br /> (2 I 6 OL —3oG 6 D 6 5-030 - 03 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BLI$INES$NAME v� �liuy/ _PCJ�/` �r' PHONE �6 Exr. <br /> HOME or MAILING ADDRESS/r, <br /> # <br /> �- U �� frflo l I <br /> CITY STATE r%� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,.,,yd.Z DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT .��/✓�t7/Q �dL�O W19Ji <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title Ei✓tf��F�R <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 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. u <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �,�U�-!rt/,D!✓Ft-���P /n��i t�iL'/�✓�' G��"GC �oR i.y G✓�S%6 <br /> 14 3 200 <br /> 01d �rn ��L� � uta- ENVIRO V1,0 <br /> ACCEPTED BY: EMPLOYEE#: DATE: S(` J " LTH <br /> RAO-A MC c Ilon 7� /�� l��c <br /> ASSIGNED TO: % n C„U O EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: a OC) P I E: qJ109 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# �1�-r Received By: bj <br /> EHD 48-02-025 n _ 1�G ORM(Golden Rod) <br /> REVISED 11/17/2003 S/a-r�� � y�= t L" "— J 'S — <br /> j/a 7- S /`rS <br /> Ior 0 Z > G ?�r� ._ C� ✓a�iS^o-, <br /> aye "tomb, — YA475 - A'S <br />