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FROM :KAISER COMMERCIAL PE- ".EUM FAX NO. :12098871904 F 21 2006 11:15AM P2 <br />SERVICE REQU, SL-- - .. <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />PHONE# <br />OWNER PERATOR � <br />DATE: <br />CHECK If B(LUNG ADDRESS <br />/ r , t <br />"t' f/l, <br />z 6 9 9 <br />HOME or MAILING ADDRESS <br />FACILRY NAME <br />FAX # <br />7 (� <br />110 ego,/ tong <br />-P l) <br />(zo,I ) <br />SITE ADDRESS c (� <br />l <br />STATE' C^j. <br />StrdE'NNumber Dlreetl <br />` Name <br />city 7ip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />CITY 11STATE <br />C.C.Ca- -P <br />Zip <br />PHONE #i En- <br />APN # <br />LAND U5EAPPL1cA-no # <br />(77&9) 3?>q- 0775 <br />PNONE #2 Exr• <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDREss El <br />COMMENTS: - - <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />PHONE# <br />Exr. <br />DATE: <br />Date Service Completed (if already completed): <br />z 6 9 9 <br />HOME or MAILING ADDRESS <br />Fee Amount: ll� <br />FAX # <br />7 (� <br />110 ego,/ tong <br />11!2. <br />S <br />(zo,I ) <br />8 6 q-- lgo <br />CITY r--+tai6r-� <br />STATE' C^j. <br />ZIP 9s7-3 6 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized anent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DIPARTMexrhourly 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, Standards, STATE and FEDERAL laws - <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / Busmm OwNFR © 01PR0. / MA -Ac. ❑. AuTuoR zxD AoiE -r <br />IfAPPcrGsrvr is not the BrcrBrcr_ r�yPdM proof of authorization to sign is required rine <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 envirotunental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is ava).tab W"81 ¢me time it is <br />provided to me or my representative. >=zcr` PI V ED <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: - - <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERMECODE: <br />P1 E: Z�(r <br />Fee Amount: ll� <br />Amount Paid <br />7 (� <br />Payment Date <br />11!2. <br />S <br />Payment Type Invoice # <br />Check # 35 <br />Received By <br />EHO 48-02-025 <br />REVISED 11/17/2003 <br />