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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO��, <br /> U CHECK if BILLING ADDRESS <br /> FACILITY NAMEIJr/� _� n � <br /> SITE ADDRESS <br /> ��it IVY ` � �+ ��� <br /> .J�J Street Number Direction VK fv Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> r <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (.2()9) u-7-1- 3bCLQ, <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RMER <br /> nAtLI , CHECK If BILLING AQDRESS <br /> G.l <br /> BUSINESS NAME PHONEE# —C#1 EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> t t t u W l4"Wxxt_.0 5-1- St (,X) ► 3(0 3— c 5�`t 3 <br /> CITY Loc u STATE-- ZIP 9 C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.HI.Al,I'li DEPARTMENT'hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,STATE;and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 12) <br /> PROPERTY/BUSINESS OWNF,R❑ OPERATOR/MANAGER ❑ OTHFR AUTHORIZED A(;ENT' &,/I(, SSlS�� <br /> ff 4PPLICANT is not the BILL/NG 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMr,NTAI.Hrnl:ili DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ,T <br /> TYPE OF SERVICE REQUESTED: ✓tT' CT RE.CEI`/r <br /> v E" <br /> COMMENTS: MAR 3 0 2009 <br /> SAN 3OAOUIN GOUNTY <br /> ENVIRONMENTAL <br /> I.iEALTN DEPARTMENT <br /> ACCEPTED BY: O L EMPLOYEE#: 0.3 Z DATE: O <br /> ASSIGNED TO: �1 r t� _ , t• EMPLOYEE#: /� I_ DATE: <br /> Date Service Completed (ifalreadyCompleted): SERVICE CODE:I�j 4�8' Pvl E: 1308 <br /> Fee Amount:*-31,5- Amount Paid 5 _ Payment Date 3 Sb o <br /> Payment Type Invoice# Check# L 3 Lk S Received By: <br /> EHD 48-02-025 SR FORM,(Golden Rod) <br /> REVISED 11/17/2003 <br />