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SAN JOAQUW-OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> Y <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 50 l cfi(- Waste <br /> 111 r.in <br /> OWNER/OPERATOR *air <br /> V6AC� C�Y �� <br /> ,( pc��. CHECK If BILLING ADDRESS <br /> FACILITY NAME (� i0`/�l ��`� ' NOV 21 lull <br /> SITE ADDRESS � ���a/ CSS {+JA =01MES <br /> LTHg5U)6 <br /> Street Number Direction Street Name / Zip Code <br /> HOME or MAILING ADDRESS/{(if Different rom Site Address) <br /> OQ J l a L Street Number Street Name <br /> CITY ' /O`4A STATE -iKA�sZIP —765, <br /> 0 <br /> PHONE#1 y ExT• APN# 1-75-170—IF,-11 LAND USE APPLICATION# <br /> ( F/7) 1 /757 I O- 611 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C <br /> J CHECK If BILLING ADDRESS <br /> BUSINESS NAME t,/k c PHONE# 22 EXT' <br /> HOME or MAILING ADDRESS FAX t#r/ J <br /> e28?0 U On (q/& lo7g 2900 <br /> CITY STATE /`it ZIP ��23 <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 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 FED RAL laws. <br /> APPLICANT'S SIGNATURE: N" ���� DATE: l/ l/ <br /> 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTV 2 L6Z L61a 15-�- <br /> IfAPPLICANT 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 REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />