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SAN JOAQUW OUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sa wJOa.gut w Fact itiw-,kM obbl <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> Sa.vvJo�agutwCou,tyP"LtEVL�i",e-i+L , Bria -Beckma*VSaL�-Ler� <br /> FACILITY ME <br /> �Ma� <br /> SITE ADDRESS Michae,7,CavlLli�Bl�vcL FrelticYl.C7000 alvip <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 44 N. Sa,t,_TmguawSt. Su4te 590 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Storkto*v CA 95202 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 915-2577 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> pv'B CHECK if BILLING ADDRESS <br /> BLtSINE S NAME PHONE# EXT. <br /> nitNTripes; Irto. 209 367-4800 <br /> HollybMAILING ADDRF S, Ste14 FAX# <br /> 1 U Ma.c4w�-( cAR1 1209 ) 367-5424 <br /> CITY Lodz, STATE CSI ZIP 95240 <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 <br /> or 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,STA nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ajC4_ DATE: <br /> PROPERTY/BUSINESS OWNER OP& TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1W usr Ccyl tractor <br /> If APPLICANT is not the BILLING PARTY.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 environrrMMEN"Invent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anVEICEWMIt is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN J <br /> ENVIROMENTAL <br /> Enwrgcy repa urs made,,to-systenv 0Tv 11/26/2012. Customer repo*rL3-t�i&SoutAEX awWPI1WM <br /> e vliA tMT <br /> senwr i.&a cwmZ W. Trouvle4hot system a U-1/f&I,wLdi fauUy sen4cr. Semsor remover a4'L&rep <br /> U4UZe4l emerge Cy, work.�iLuatfaw <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: -1 ' Amount Paid `*37 T,-V'0 I Payment Date ,),q(f <br /> Payment Type Invoice# Check# �b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />