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• r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI_ DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />9 (, /) T/�C. <br />6. Ji 1 <br />FACILITY ID # <br />HECK If BILLING ADDRESS ® <br />SERVICE REQUEST # <br />/'nvL e sP <br />rev <br />s�� <br />HOME or MAILING ADDRESS <br />S 200 OL2 M <br />OWNER/ OPERATOR <br />FAX # <br />g <br />/� <br />G (E t,D NI A ti m <br />GA R &j A 19� � t M Frit 5 CHECK If BILLING ADDRESS <br />FACILITY NAME <br />CITY M P /J Fr-, C� <br />SITE ADDRESS <br />I <br />/'I�.�. �f G,(_� <br />LJ" <br />EMPLOYEE#: <br />�OOI <br />/ 1 <br />y'.Sa. 4V <br />J L/ Street Number <br />Direction <br />Street Name <br />D/ (,�G <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />F <br />Fee Amount: <br />4 Sir zt O - O�D <br />Street Number <br />Q\0 -- <br />Street Nam¢ <br />CITY <br />Payment Type <br />STATE ZIP <br />PHONE#1 EKT' <br />#. <br />APN-0.15 <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />SOS DISTRICT <br />—11 <br />LOCATION CODE <br />1 I <br />Lf <br />CONTRACTOR / SERVICE REQUESTORCwt4c r <br />REQUESTOR <br />�} POOL <br />9 (, /) T/�C. <br />6. Ji 1 <br />C�'//— 'z'o //� /1� <br />HECK If BILLING ADDRESS ® <br />BUSINESS NAME <br />AOLU� <br />/'nvL e sP <br />rev <br />PHONE# xT <br />lei s` i¢ <br />HOME or MAILING ADDRESS <br />?LVD- <br />MAR 1 7 20009 <br />FAX # <br />g <br />Mvi--( 4-r <br />SAN JOAQUIN COU <br />Mt!YTW Tl' <br />(ao9)� <br />CITY M P /J Fr-, C� <br />R. <br />n <br />STATE I n <br />ZIP 7 t ? 3 <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 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, STATE and FEDE r <br />L I s. <br />APPLICANT'S SIGNATURE:/�//� _ DATE: C>,3 _/ } / q <br />PROPERTY/ BUSINESS OWNER❑ "OPERATOR/ MANAGER Ltl OTRER AUTHORIZED AGENT 6) <br />{%APPLICANT is not the BLLL7NGPARTP proof Qrauthorizadon 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 ENVIRONMENTAL HEALTH DEPARTMENT 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: A�G f-1 g-4-- 4 <br />/�K O,d C, <br />j'L �+� GILT g—00A <br />COMMENTS: <br />CEt VrD <br />MAR 1 7 20009 <br />SAN JOAQUIN COU <br />Mt!YTW Tl' <br />HE-ALfA <br />ACCEPTED BY: <br />t �� <br />©`1 UE032-( <br />EMPLOYEE#: <br />DATE:3 <br />ASSIGNED TO: <br />QC �S <br />EMPLOYEE#: <br />D/ (,�G <br />DATE: <br />Date Service Comllp�✓feted (If already completed): <br />SERVICECODE: .�2'Z <br />PIE: 0 Z <br />Fee Amount: <br />4 Sir zt O - O�D <br />I Amount Paid <br />Q\0 -- <br />I Payment Date 3119 Q U <br />Payment Type <br />✓ <br />Invoice # <br />Check # $ <br />Received By: <br />EHD 45-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />