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.121,05%2008 17:00 12095453848 OFFICE PAGE 01/02 <br />SAN JOAQUIN COUNW E' NVIRONMENTAL HFALm DEPARTMENT <br />SERVICE REQUEST <br />Tvoe of Business or Property <br />CHECK M BALING ADDRESSE1 <br />FACILITY ID IR SERVICE REQUEST ✓e <br />tep <br />I rA, <br />0ouz4�?� 0 <br />OWNI:RIOP51RATOR <br />EMPLOYEE rJ: DATE: E <br />CHECK If dILUNG ADDRESS <br />FACIUTY NAME r� <br />oS <br />DATE: <br />SITE ADDRES/5, <br />C c,/V -k �i 6-4 h t- <br />/ <br />I.J h <br />� <br />r'7 Strea Number blracti� <br />509et NangC' <br />zi Coda <br />HOME or MAILINGADORES5 (If Different from Site <br />Addreas) <br />Invoice# <br />S- v Hamner raet Name <br />CITY <br />S 4p1€ �P <br />PHONE#1 <br />APA{ <br />LANG USE APPLIGAT ON A <br />PHONE R2 E'T <br />f ) <br />SOS DISTNICT <br />LOCATION cot) <br />rnrr ru a CTOR / 9FRVTCE REOUESTOR <br />VI rY'�.�awur.-�Iv� (ry ����. ... <br />REQUESTOR ,(/rq�� Iq t,i.(lf �ln ,I A�� <br />CHECK M BALING ADDRESSE1 <br />�I'^'1'J <br />BUSINESSNAME <br />r <br />��l.f�'trLi o� i�'a�l� v4Rr2at`�l <br />HOME or MAILING ADDRESS f <br />A <br />Pate# <br />EMPLOYEE rJ: DATE: E <br />CITY I STATE <br />7JP <br />131LI,ING ACICJ'7&OVIUDGEMEN : I, the undersigned property or business owner, oper aiur to a...rr.ar..c„ esu... 01 o».A•, <br />acknowledge that all site and/or project speciflo 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, 8CAAT1E and RRAL laws. <br />C APPLICANT'S SIGNATURL: DATE: <br />PROPERTY/ BusasFSs 0wNaR13 62511TOR 1114ANAGPA JD OTH6n AUTRORIZEp AG79 <br />If APPuCAHP is not the Sn:LbVQPARTY proof of aHthorizadon to sign is required Titi e <br />AUTHORIZATION TO REINFORMATION: 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 crlvironmental/site assessment <br />information to the SAN JOAQUI14 COUNTY ENYIRONMzxTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provroca w a,c o, uq <br />TYPEOF SERVICE REQUESTED:— <br />(✓ <br />OOMNEtrra: ,,...— r <br />ac,�- <br />r <br />��l.f�'trLi o� i�'a�l� v4Rr2at`�l <br />� <br />ACCEPTED BY: <br />EMPLOYEE rJ: DATE: E <br />ASSIGNED TO: <br />EMPLOYES It: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CoOE; 6 <br />PlE <br />Fee Amount `b <br />Amount Paid '� Q s <br />Payment Date L <br />Payment Type M <br />Invoice# <br />Check# <br />Received By: <br />EHO 4802,025 <br />REVISED 11117=03 <br />SR FORM (Golden Rod) <br />AYMENT <br />ECEIVED <br />:C - 5 2008 <br />JOAQUIN COUNI- <br />WIRONMENTAL <br />LTH DEPARTMEN- <br />