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10/09/2006 15:30 70744661 9 <br />TANK—TEK <br />0 <br />SAN JOAQUIN COUNTY ENWRONMENTAL HEALTY-T DEPARTMENT <br />SERVICE REQUEST <br />PAGE 03 <br />of Business or Property F CILITY ID # <br />SERVICE REQUEST # <br />Zpe <br />SO =1 Jl�, �" C,l � l � <br />OVAER I OPER O <br />CITY STATE ZIP r7 <br />DATE: I & <br />CHECK If BILLING AGORE&s <br />FA I } <br />EMPLOYEE M °— lC T] 0 <br />SITE ilnnaa cc <br />tT � NlimGir I`( ` <br />I El''1C 2311 <br />Imo"' "�� q <br />Zlp Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />SER%ACF 000E; <br />S root Nombor <br />stTellt Home <br />CITY <br />STATE ZIP <br />PHONE #1 Ext. <br />APN # <br />LAND Use APPLICATION # <br />%) S1 <br />Invoice # <br />PHONE 02 Err. <br />BOS DISTRICT —7LOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUATO <br />cayscx IF s LLING AlaoaEss <br />BUSINESS N <br />N� t" U,y Exr. <br />- I <br />HOME or MAILING REBS• <br />V <br />F?C#�) <br />CITY STATE ZIP r7 <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 IrNVTRONNIRNTAL T -TEAL TH DFPARTMFNT hourly charges associated with this project <br />or activity will be billed to me or nay business as identified on this form. <br />I also certify that T have prepared this application and that the work to be performed will be done in BCCOrdancc with all SAN JOAQUIN <br />COuNTy Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE; �� DATE: x�eO (? <br />PROPRRTV / BUSINESS OWNER❑ OPERATOR 1 MANAGrn ❑ OTrirR AUTTFORIzrm AGENT r <br />1fAPPi.rcA.ivT is not the BILLING PARTY. ,proof of authorization to sign is required T+tic <br />i1THORIZA—ION TO RELEASE INFORMATION: When applicable, 1, 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 assMMIEIi T <br />infO=RtiOn to the SAN JOAQUIN COUNTY ENVTRONMENTA.L REALT14 DEPARTMP-NT as soon as it is available and at the same R <br />t IVED <br />provided to rue or my representative. i -S CIG <br />TYPE OF SERVICE R��-E�Q.uCs ED: <br />OCT <br />��- j p� <br />COMMENTS: CV I D �' ew �, e C 1 � � l/} �5� 1 `��An <br />�/�� new <br />�, SAN JOAQ <br />mo, <br />a l 0 l -, ovi J� . HEALTH D <br />�ti�`io <br />Mai dA -j, ; I r���ec�Qt� Vea <br />ACCEPTED BY: G)L Cc E. [ LO +�c <br />EMPLOYEE C, 3//Z. ( <br />DATE: I & <br />/- <br />ASSIGNED TO: iv C r� �� <br />EMPLOYEE M °— lC T] 0 <br />DATE: Z 3 ( C: <br />Date Service Completed (if already Completed): <br />I <br />SER%ACF 000E; <br />PIE: "2 � t' � <br />Fe® Amount. R2 <br />Amaurlt Paid <br />OO <br />Payment Date <br />O a 3 b <br />Payment Type ,. 'J <br />Invoice # <br />Check # / --)-5-1 Jl <br />Received By: <br />EHO 4802.025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />3 2006 <br />IN COUNTY <br />MENTAL <br />PARTMENT <br />S. <br />