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0AIV J VAINUlIN t,V U1N 1 Y L'1V V 11CV1NIY11L1N 1 AL K11LAL 1 ri 1JEYAK I IVI 6IN 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If �b If <br /> Res i Aul�a-,( <br /> OWNER/OPERATOR <br /> Tl Qvn �CV Vbr� CHECK If BILLING ADDRESS <br /> FACILITY NAME �[ <br /> SITE ADDRESS <br /> �1016be W� 5 D✓� IQGQ f /3�Qin o �� �SZzp <br /> Street Number Direction Sire ef Name Ci I Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN If LAND USE PLICATION# <br /> I - o as 4 - 09 oe�ZZZ �,KS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ((�� <br /> ��(r r/e F. 5,,, 7(i CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS _ FAY# <br /> J -,5---5— .�o n 1 ) <br /> CITY / _ STATE zip q5a� <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,Standards TE an FED L laws. <br /> APPLICANT'S SIGNATURE: DATEgt j Z 0!7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NLLNAGER ❑ OTHER AUTHORIZED AGENT ��{l(L Fi A_ <br /> IfA,PPLICANTisnoIthe BILL/NGPARTY 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: /F6(/1 4.4', J eL i AG- bi NT <br /> COMMENTS: RECEfV <br /> ii/a/Oy ) OCT 2 e 2009 <br /> It/10/01 �� h7i� i?�Gr�:./ SAN JOAOUIN COUNTY <br /> rte _(YJy,G' ONMENTAL- <br /> H�7H DEPARTMENT <br /> ACCEPTED BY: L V ;S L ,q _� EMPLOYEE If: O 324 DATE: /O 2&lO <br /> F�Tf <br /> ASSIGNED TO: vyvc—Jj r N EMPLOYEE#: -5�3&6 DATE: I O Z.e/o <br /> Date Service Completed (if already completed): SERVICE CODE: 5 ZZ- P I E: .1-I[� <br /> Fee Amount: �3 Q , Amount Paid �--3 CJ Payment Date <br /> Payment Type Invoice# Check# ' Received By: <br /> EHD 48-02-025 - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />