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SAN JOAQU ';COUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY[D� SERVICE REQUEST# <br /> GGIlSC%D G�✓ Fic L � i� �� O v d S 6 SIZOf>f0.3�1 <br /> OWNER/OPERATOR _ _ <br /> SAW <br /> �O�,(���� � �� �/�,��O ���� G1I�� ter CHECK if BILLING ADDRESS E] <br /> FACILITY NAME eenpR� <br /> SITE ADDRESS vv//�` /!/L (lP/�'/ �fUl� Gdl✓ R1� 71FAZ y 1,M? 77 <br /> 3//3 0 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Diff'erent from Site Address) <br /> �O /-?0>(` O Street Number Street Name <br /> CITY � STATE ZIP <br /> PHONE#1 EXT. APN# , LAND USE APPLICATION# <br /> ( 09) 1�e� Ly— 3v'66 a 3'3-0 3D v <br /> PH NE /7gU EXT. BOS DISTRICT LOCATION CODE <br /> oe) �4/- .71 1717 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> / /f/J/C�lst��-L C���� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �A,.,/��� �,�'r ��� PHONE# EXT. <br /> HOME Or MAILING ADDRESS �•V �r N /� FAx o? ) f4 P r 307 O7 <br /> CITY <r� �i� ` STATE e� ZIP "9: � <br /> BILLING ACKNOWLEDGEMENT: 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 <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 w to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE s <br /> APPLICANT'S SIGNATURE: DATE: O %o`er �/// ,+► / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT� sc~/"x owe <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 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: r✓�Dp i✓�3E�C /Ndh///pVX//✓_��15/E� ,��/L L�jp/� n�iell✓J/ <br /> COMMENTS: A0 /«/�/ r c/l /�j//f �Ae <br /> /�r/S• �ip,"i os= 3 /(/Ei✓ �2�.✓,pG✓F>��r �rc�r�r1.+er <br /> /1001/ <br /> 3 <br /> �/oAve !L L% %JG s ib r��o�✓� <br /> /✓a i / �(/+'/ <br /> A. <br /> ACCEPTED BY: -� �� � 7` ^k-�✓� EMPLOYEE#: �%�,$ DATE: <br /> ASSIGNED TO: � �'p � �A�j�-�p�` EMPLOYEE#: DATE: C✓��//� <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E: <br /> Fee Amount: '-2D-75 1Amount Paid 3-�� Payment Date 9/71 <br /> 11 <br /> Payment Type S S'1"_ Invoice# Check# E Ar EW Received By: L6 <br /> CO I-ZLJ <br /> SEP _EHD 48-02-025 ?o�� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 SA <br /> �1//9��i— OGr rc!rix;d�`•i + `g/�,r'�ce./�!r'� µ�yN !I f�� UJ <br /> ,.�N ro <br />