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SAN JOAQUV-"OUNTY ENVIRONMENTAL REALTY DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SFZO O 5 1 SOS <br /> OWNER(OPERATOR /t/ / �/�/ <br /> u ,i CHECK if BILLING ADDRESS® <br /> FACILITY NAME �LY� z(l lJL <br /> SITE ADDRESStr� /I wit <br /> /� tne�� 15330 <br /> Street Number Direction Street Name Ci ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE/)� ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> caq ) 59f5- Joe) , 070 , 04 _R --O0U _ <br /> PHONE#2ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR t� <br /> REQUESTOR <br /> ` ` v CHECK If BILLING ADDRESS N <br /> BUSINESS NAME✓ PHONE# T' <br /> �nt 2a4 sy$ 4 od <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) 124 <br /> CITY STATE ZIP �l <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 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: LIMq DATE: <br /> PROPERTY/BUSINESS OWNER PER IED AGENT <br /> L/ R $rt Z y-. }�� <br /> IfAPPucdxTis not th ILZ <br /> PARTY proojojauthorization to sign is required 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 /> infOmlation 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 /> TYPE OF SERVICE REQUESTED: s <br /> Com EENT. : C� RECEIVED <br /> ��( 7 AUG 2 200 <br /> SAN JOAQUIN COU <br /> ENVIRONMENTAL <br /> H DEPARTME <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: Q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 672, PIE: ZQ <br /> Fee Amount: N Amount Paid '� �'� Payment Date �`t p 7 <br /> Payment Type L/ Invoice# Check# Ifr-( 7, Received By: -0., <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />