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OnA2008 14:23 Fi X, '17074466192 TANK-TEK [6003/004 <br /> 1 14 <br /> A .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> vAta+N r;uuNTY SERVICE REQUEST <br /> Type of 90WIiii0b"+61 erty FACILITY ID# lJ6 SERVICE REQUEST# <br /> Fif:tiLl HDEPARTMENT <br /> . .r <br /> OWNER OPERATOR. <br /> m o 6 CHECK If BILLING ADDRESS <br /> FACILITY NAME Q C <br /> SITE ADDRESS r/ ae Z <br /> 41 Street Number rectfan Street Name CIryZI o <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITY STATE zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 4 0 S�L <br /> PHONE#2EYr. BOS DISTRICT LOCATION CODE <br /> c ) 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU ESTOP/ <br /> CHECK If BILLING GAA DO t�E y4 t...l <br /> BUSINESS NAMEr— PHONE# ErT <br /> S1 <br /> *i MAe-O"rtAIADDRt=SS FAX# L <br /> Q ) N— <br /> CITY STATEG� ZIP q 6 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned p, business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMG hll,'-ALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified , n ais form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUfN <br /> COUNTY Ordinance Codes,Standards.STATE- and FGDL-R.AL laws. <br /> APPLICANT'S SIGNATURE: / // DATE., wi <br /> PROPERTY/BUSINF,55 OwNERO OPERATOR/]MANAGER ❑ OTHER AUTHORIZED AGENT T <br /> If.APPLIC,9NT is not the BILLING A,fRTY,proof of authorization to sign is required Tlr e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1, the owner or operator of the property locuted at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmcwsite assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART.MLNT as soon as It Is avuilablc [n1CGL�4rnC It is <br /> provided to me or my representative. C / <br /> TYPE OF SERVICE REQUESTED: /,, S 1 <br /> COMMENTS: UAL,_/1n {—� n 9 `CLL I/ GLS e- C�I1 I �AJVIG <br /> t0.tGrpLl,{.c'3 J� F�oqQ�� CUU� <br /> /9N,, COO, <br /> ��p� � �ie <br /> 0 N ITiy(�L�• n 3eJt[,A,Y� o S�1 l 17� t,►tt.M �ct�� 0 7 1 �I l��ry�F�Try <br /> �Xa`a'"� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> A33IONEU TO: EMPLOYEE#: Q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: D <br /> Fee Amount:Crr/aAmount Paid 29 400 Payment Date (Y� <br /> Payment Type Invoice# Check# (�2 Recelved By. <br /> EHO 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />