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06/19/09 04:31PM HP LASFRJET FAX 2093690906 P.03 SAN doAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of BLlclness or Property FACUM 1D S COWAE ! SERWE REQUEST OWNER OPERATOR e C. Hu Gr1EGRtr8N.U1G ADnNESS❑ FACMITY NAME 5 EMPLOYEES: DATE: TS1MAoeRM Iq Semel N,.rbw o' m �� Lw �: ♦�A Sealm com �}�. .t r l�- q a Z2.O HOME or MAILING AWRESS (if OBFerent horn Site Address) Sitaat N PaymNxrt Data Payment Type CrrY Check f STATE 7JP PaoW#dEM APMA 1 ) Wn11SE APPUCAMK# PHW#2 ET. ( 1 BOS OsTstcr LocATron CooE CONTRACTOR I SERVICE RE UESTOR BU.LTNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborircd agent of same, acknowledge that all site andlor project specific flNvraoNmEN-r.4L HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to we or my business as identified on this form I also certify that I have pteparcd this application and that the work to be perfnmted will be done in accordance with all SAN IOAQUIN COUNTY Ordinance (odes, Standards, STAA and FEDERAL laws. APPLICANI'SSIGNATURE: DATT: lIA 9 _ PROPERTY/ BUSINMSS OwNER0 OPERA'MR/ C" ❑ OTHER AtrtnOatrED Aa:aNT (ff ..FD TfAPPLIGaNr is not the Bn.zgNGPARTY. authur¢ation ro sign is required Thf, AUTHORIZATION TO RELEASE INFORMATION: When applicable, 14 the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY fNvlRo[JkmmTAL HEALTH DEPARTmEtTr as soon as it is available andd at the same time it is provided to me or my representative. TYPE OF SERvtcE REGuesma: M COWAE ! AcCEPIED By: C. Hu `.h3 . w �• � EMPLOYEES: DATE: Date Service Completed fdaY�dycomMemd): Lw �: ♦�A Sealm com PIE: Fee Amount Amount Paid BU.LTNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborircd agent of same, acknowledge that all site andlor project specific flNvraoNmEN-r.4L HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to we or my business as identified on this form I also certify that I have pteparcd this application and that the work to be perfnmted will be done in accordance with all SAN IOAQUIN COUNTY Ordinance (odes, Standards, STAA and FEDERAL laws. APPLICANI'SSIGNATURE: DATT: lIA 9 _ PROPERTY/ BUSINMSS OwNER0 OPERA'MR/ C" ❑ OTHER AtrtnOatrED Aa:aNT (ff ..FD TfAPPLIGaNr is not the Bn.zgNGPARTY. authur¢ation ro sign is required Thf, AUTHORIZATION TO RELEASE INFORMATION: When applicable, 14 the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY fNvlRo[JkmmTAL HEALTH DEPARTmEtTr as soon as it is available andd at the same time it is provided to me or my representative. TYPE OF SERvtcE REGuesma: COWAE ! AcCEPIED By: EMPLOYEE if.DATE ASSIGNED= EMPLOYEES: DATE: Date Service Completed fdaY�dycomMemd): Sealm com PIE: Fee Amount Amount Paid PaymNxrt Data Payment Type Invoice tl Check f Reeefved i3y: EHO 4M2-025 REVISED 11117=3 SR FORM (Golden Rod) Cd 629L-9LL-9Z6 uoipelea >ee-1 uois(oeJd dZb:VO 60 6( unf