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---- cam__ •��••1 1 Lig rtnvl�irl�1V1AL fIEAL1ri LL+YAl-,IINIENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: (�_ <br />SERVIC�;REQUE�ST# <br />ACCEPTED BY: ,n <br />V L,(V <br />l7-757 <br />� K� <br />OWNER/ OPERATOR El <br />FACILITY NAME <br />DATE: 11174 <br />Q <br />r <br />SITE ADDRESS 1 r) It)Q_ r� 1 tl <br />Street NumberDirection <br />Street Name Cit � i CodE <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P i E:D <br />Fee Amount: 31 S v O <br />Amount Paid 3 � V p <br />r <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATIO CODE <br />CONTRACTOR / SERVICE REOUESTOR <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 or <br />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, ,Stand s, STATE and FEDES. <br />APPLICANT'S SIGNATURE: ^ �,t ;`, 3,W <br />^ . i I I An <br />1 DATE: V <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑. I OTHER AUTHORIZED AGENT(' <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is reguir d 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: LLS r— <br />COMMENTS: (�_ <br />AEI-' t <br />JUL 17 2009 <br />SAN JOAQUIN COU <br />ENVIRONMENTAL 7Y <br />HgLDEPAR <br />ACCEPTED BY: ,n <br />V L,(V <br />EMPLOYEE #: p 3 � ./ <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: 11174 <br />Q <br />Date Service Completed (if already completed): <br />SERVICE CODE:/ F$ <br />P i E:D <br />Fee Amount: 31 S v O <br />Amount Paid 3 � V p <br />r <br />Payment Date <br />Q <br />Payment TypeInvoice <br /># Check # <br />Received By: <br />EHD 48-02-025(Golden Rod) <br />REVISED 11/17/2003 <br />