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,. ....��.1v,,. vvi.AA IMk'NI <br /> SERVICE REQUEST <br /> mess or Pptlerty FACILITY ID# SE FQ51W <br /> lid arta r �, 12� S,eo � <br /> NER 1 OPERATOR <br /> J CHECK If BILLING ADDRESS <br /> ( I r a ra.T"/off\ <br />' FACILITY N ME <br /> U 1 tr ,c•.l LaU►�lr <br /> SQtTEADDREss f�vn heir Street Name Citk+ori Zi Code <br /> 95Zo Z <br /> ' V I� Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) (�yy ci eb; <br /> Street Number c^ Street Nam <br /> CITY IDIJ STATE Zip <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (90cr) Ctti t g36Li � 3 X053 t L-1 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> i 1 <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS ElF—nulronmeAh { rn an C rar,1(1n ZnC <br /> BUSINESS NAME PHONE# EXT <br /> Par Lce,, C( Ort Uc, ( /`i 667-230 <br /> HOME Or MAILING ADDRESS FAX# <br /> Sante a Coq ( it[ 6Gx-23d <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEMENT I, the undersigned property or business owner, operator or authot ized agent of sante, <br /> owledge that all site and/or project specific ENVIRONntLNTAL HrAi ri t DLrARTMI'N I hourly charges associated with this project or <br /> tvity will be billed to me or my business as identified on this foim <br /> I also ceitify that I have piepared this application and that the work to be perfoirned will be done In acLoidance with all SAN JOAQUIN <br /> ' COUNTY Or(Imance Codes,Standar ds,STATE and FEDE I <br /> APPLICANT'S SIGNATUREDAZttEpptt_ 1 Z 11 z f <br /> PROPERTY/BUSINESS OWNER❑ OI'ERATOR A'IANAC£R ❑ OTHEIi AUTitOttlZFD AGFNT <br /> 1fAPPL1CANT is not the BIl LIA'G PARTY proof of authorization to sigis is requited Trite <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 /> infon-nation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL.In DEPARTMLNT 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 9 m va + PAYMENT <br /> do <br /> COMMENTS RECEIVED <br /> DEC1� 'Nr fj 5" <br /> 12 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY D` VVf'J EMPLOYEE# 8 3 f DATE 12, tri rl R <br /> ASSIGNEE)TO M/`_ EMPLOYEE# V3 S V v DATE f L r ' <br /> !Date Service Completed (if already completed) SERVICE CODE t PIE Z Z <br /> Amount t 1 rG . �� Amount Pard (,�� ftp �J Payment Date j �j , � J <br /> i Payment Type '-I 0 [nvoEce# Check# Received lay <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />