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BUSINESS NAME t, <br />HOME or MAILING ADDRESS <br />ck TCk khitAA-crAn <br />PHONE # EXT. <br />) <br />FAX # <br />) <br />SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DErARTMENT <br />SERVICE RE <br />j Type of Business or Property <br />i <br />'kV..‘rtC, Vtg\C\rj <br />FACILITY ID II SERVICE REQUEST # <br />/ i <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />Elicit ITV NAME <br />SITE ADDRESS still% <br />I StrerA Number 1 Direction \MA170.• SiN\tt.r; Name V"-Ale4:41C) <br />City (15-1,9V <br />HOME Or MAILING ADDRESS (If Different from Site Address) 1 <br />C t lcl WM A-50V\ 01/V-e,i Street Number 1 Street Name <br />Zip Code <br />CITY <br /> <br />STATE A ZIP AfkiSC\-C1 CV+ Ac '779- PII0f.:1 ill EXT <br />(-704t — 'cots. — `11 7A-, <br />APN # LAND USE APPLICATION # <br />PHONE ,t2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />EQUESTORr-- <br />AAb4 v'4 V\ <br /> <br />2( CHECK if BILLING ADDRES)S <br /> <br />CITY STATE cot ZIP cs\c--,..-5•9 <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 ENviRONI,IENTAL 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 />4111111111110.1.0.- <br />APPLICANT'S SIGNATURE: <br />si•..t/Z1P— DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATar: / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PAR71. proof of authorization to sign is required <br />isle <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: r <br />J6 It IIECEIV COMMENTS: ED <br />A:01 Q7A1 <br />AU <br />: <br />G 2 1 20ig S <br />H ,AENviRoNm couNry DE , ENTAL <br />ACCEPTED BY: VI (Air EMPLOYEE #: at 732._ <br />rAfTivr <br />DATE: <br />ASSIGNED TO: VI Cifill EMPLOYEE #: q 3'32- DATE: / / /7 <br />Date Service Completed (if already completed): SERVICE CODE: 0(,) P/ itfiO3 <br />Fee Amount: 69- - dd Amount Paid 4 (s-e,,__ _____ Payment Date <br />Payment Type Invoice # Check # Received By: til) <br />EHD 48-02-025 SR FORM (Golden Rod) <br />0717.08 <br />ew-r-A110 <br />I also certify that I nave prepared this application ai that the work to be performed will be done in accordance with al.1 SAN JOULIIIJ <br />COUNTY Ordinance Codes, Standards, STATE and FIERAL laws