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HOME or MAILING ADDRESS (If Different from Site Address) <br />Orr <br />Street Number <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />FACILITY ID # Type of Business or Property <br />e-- <br />OWNER! OPERATOR <br />.-0./t// 4 4.7hyl &II P-z) <br />FACILITY NAME r.J 11.1 "3.41,0 <br />SERVICE REQUEST # <br />ift) <br /> CHECK if BILLING ADDRESS El <br />SITE ADDRESS <br />1.5-0 agifhPO BID S- n046 <br />street Name <br />m City Zip Code <br />Street Number Direction <br />Street Name <br />STATE ZIP <br />EXT. PHONE #1 <br />czeor ?3-9 / <br />PHONE #2 <br />0,7z, LAND USE APPLICATION # <br />BOS DISTRICT L/OpTIONAE <br />CONTRACTOR / SERVICE REQUESTOR <br />R- <br />A;e1IiCen—( c&$ /71-4"5712 mi< revc-- <br />awt ) '?Y 3 5/7 <br />pHoNot <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 />DATE: <br />OTHER AUTHORIZED AGENT <br />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 OF SERVICE REQUESTED: fA41-rje. car -‘'Ni <br />- <br />COMMENTS: <br />1-1 <br />OM( 2, 7 10-'° <br />c.f,t4 <br />'-' 00 1 BONN,L--_,Nvqi- <br />k-keAlj" DEI*"I <br />ACCEPTED BY: <br /> 5W H. <br />EMPLOYEE #: .-1;S:Ac:p DATE: <br />ASSIGNED TO: OW Pur--s-D <br />EMPLOYEE #: 0 46q. DATE: <br />PIE:El„...}___63 <br />Date Service Completed (if already completed): SERVICE CODE: 6-6 <br />Fee Amount: g Amount Paid sof n Payment D te 31 <br />Payment Type Invoice # Check # —2_ 2_,(,) S-2._ Received By: <br />CHECK if BILLING ADDRESS El <br />94"111111-70 02..4ve-e" <br />HOME or MAILING ADDRESS <br />beesetCcr- /20 <br />Crry <br />Cer <br />PAX # <br />ge)f e <br />*06- <br />I also certify that I have prepared this application and that the w <br />COUNTY Ordinance Codes, asiWStandard ; FEDERA <br />_-.......ro 're .../....aille.c WIPP"- <br />PROPERTY / BUSINESS OWNER 0 I PERATOR / MANAGER 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />APPLICANT'S SIGNAT <br />performed will be done in accordance with all SAN JOAQUIN <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003