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CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS EJ <br />BUSINESS NAME <br />HOME or MAILING ADDRESS <br />PHONE # <br />S,C <br />(-J <br />FAX # <br />LA <br />.0c, At Er an 1-cf.r)e <br />ZIP 75)6 ,c STATE <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE U <br />Type of Business or Property <br /> F-7)-(306 .2 7 4 1 <br />FACILITY ID # SERVICE REQUEST # <br />c-, izoa 79/ cci <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />Faciure NAME lith cr r : i cl <br />li cf f—C 4--Pcr r t )41 rai t'.S SITE ADDRESS <br />Street Number Direction <br />I <br />/ilk c. i Y1 ( r s 1.),r. <br />Street Name S1--r)c.k 4 ob-, <br />City HOME or MAILING ADDRESS (If Different from Site Address) I <br />Street Number I Street Ndme <br />Zip Code <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. I APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />I--- f <br />I, 1 BOS DISTRICT —1 <br />I <br />LOCATION CODE <br />6 J <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEAI TH DEPARTMENT hourly charges associated with this project 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 COUNTY Ordinance Codes, Standards, STATE aEDERAL la <br /> <br /> DATE: S — 2 ?.. - 13' <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT gl i',,-,-, C 4 7, ,Y1 P'/\ 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 above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same Urne it is provided to me or my representative. <br />APPLICANT'S SIGNATURE: <br />Ai TYPE OF SERVICE REQUESTED: 7 610\ te//44-o--d-er '1"C'ell <br />yk <br />71,f , <br />COMMENTS: <br />441/ <br />/1 14 <br />i;11)141:4ft14/41 <br />ACCEPTED BY: #... L. -c -.. ASSIGNED TO: ---v <br />i., EMPLOYEE #: (e z i 3 ; DATE: _ <br />,---___ EMPLOYEE #: Z4 DATE: illir <br />Date Service Com eted (if already completed): SERVICE CODE: <br />Fee Amount:Amount: <br />750 i Amount Pals;;. ••• DD c-' Payment Date I <br />Payment Type .);./..„_ Invoice # Chey4 # 5-y". 75.1s--3 A Received By:Zi ..,._ <br />.EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)