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I <br /> SAN JOAQU 7OUNTY ENVIRONMENTAL HEALTI ;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CQ A5 'S-(AT(bIQ � Se 0 015, � kr2- <br /> OWNER <br /> /OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Street Name city Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 �� S: 3 LI_t� t(4 <br /> Street Number Street Nam <br /> CITY Pto V 6 <br /> 1 STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATIONCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �7 1 PHONE EXT• <br /> ev t.Com. Sta�-� t�ups . Z"�e . -•f�� �C3- X03� <br /> HOME or MAILING ADDRESS FAx# <br /> ('-Sl` C%avievLt Ave- (q&) <br /> CITY , ` OC „ <br /> STATE ZIP j 1 <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 1 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. .11 Q <br /> APPLICANT'S SIGNATURE: u(Q � �, DATE: r�a2 /t 0,5 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Is lCIL-m"a' (f <br /> /fAPPLICANT is not the BILLING PARTS',proof of authorization to sign is required It Title <br /> AUTHORIZATION 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 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: U S 09-IF-7-:12-0 F ( 7— PAYMENT <br /> � � <br /> COMMENTS: <br /> ka-k- CL6P-c 4cv Y-e f u.-F MAY 2 8 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: O C_ ✓i[` EMPLOYEE#: 032—t DATE: .S <br /> ASSIGNED TO: d fJ t r EMPLOYEE#: ZL� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:!9k P I E: <br /> Fee Amount: _ 3 l '5 Amount Paid 3 15 Payment Date 2�/ Q <br /> Payment Type ✓ Invoice# Check# b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />