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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT <br />MERAWMARM <br />Type of Business or Property <br />CGrl3e"v Cf1✓1-)R <br />FACILITY ID # <br />C V% —h14 -- DO S <br />SERVICE REQUEST # <br />OWNER GPITIROXTIM <br />�-� �V�/ ��I� C(/ "' ��/ / — /- �i//�LIC ��✓(/l�/`-J ,L/�/ '"'slfZi4CHF,Cf( If BILLING ADDRESS <br />`r'/JJ� <br />FACILITY NAME /�97 /7 /2L <br />C�///C 13�®/7 <br />SITE ADDRESS <br />Street Number <br />�1/,`?� <br />Direction <br />L�!/.Z'i�'�42 6` i%Z-GUS/ k4l <br />Street Name <br />city <br />7 7 <br />Zia Code <br />HOME or MAILING ADDRESS (If Different from Site Address) / e1o�ZLCL� <br />Street Number <br />Street Name <br />CITY S,��Z �j STATE e d ZIP <br />/` f .3 <br />PHONE q#t <br />3,,,r EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT <br />( 1 <br />BOS DISTRICT -�7LON <br />OCATI CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , ` "L <br />!^' <br />CHECK if BILLING ADDRESS <br />/ <br />BUSINESS NAME -04W �'/��u�� C�tN� y�p �.aGZ/� <br />J V'r ! <br />PHONE# <br />go <br />f <br />—Tag, <br />�G 6' —T(� i9 <br />N6MEOP MAILING ADDRESS ! ® ry s / <br />FAX �„ 0 <br />7 I/ <br />CITY �� ��d�Z i STATE <br />C,54 <br />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 1 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 FE RAL laws. <br />APPLICANT'S SIGNATURE: Z�4 <br />DATE: Al-soZ <br />� ,y �7 <br />PROPERTY / BUSINESS OWNER ❑ ' OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT r? rc+ <br />If APPLICANT is not the BILLING PARTY, proof of authorization 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 />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 <br />gREQUESTED:/ r� ^ r� ,r <br />COMMENTS: D/eg%CG IA14 /(FR�/% /X'ZiX AQ le el/le2- <br />Arlo- f3J'i�6�j ff%°Z <br />1 <br />ACCEPTED BY: a <br />EMPLOYEE#: 4x 10 <br />DATE: /--7 <br />ASSIGNED TO: rt. <br />EMPLOYEE #: W <br />DATE: -///.r/07 <br />s <br />Date Service Completed (if already completed): <br />SER VICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />f Invoice # <br />Check # <br />Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />