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SAN JOAQUINOUNTY ENVIRONMENTAL HEALTH DIARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G STOP-L- -3-7 ( G � <br /> OWNER/OPERATOR <br /> MA T-,� >✓ G 10, CHECK If BILLING ADDRESS <br /> FACILITY NAME UPEI�Z <br /> SITE ADDRESS 29C) I'j. SIT.. �A T t=Cad F:?53 (-3 <br /> Street Number Direction Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t—7 S- S� 7 kC—e-- Street Number Street Name <br /> CITY ��C �O� STATE ZIP <br /> (fA '��206 <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (LCq) z3 i.� r-rs y-?3 - oG _ o/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATI ODE <br /> ( o ► -732-6 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A-1-i-7 <br /> t_.-,'/ t J—7 -6 4 3 0 9 V�E CHECK if BILLING ADDRESS <br /> BUSINESS NAME �''� PHONE# EXT. <br /> U� <br /> HOME or MAILING ADDRESS FAX# <br /> u ( ) <br /> CITY STATE zip <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 ST�FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: ©S• <br /> PROPERTY/BUSINESS OWNER El OPERATOR/ NAG ER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING 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 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: q <br /> COMMENTS: MEND <br /> (�S J RECEIVED <br /> MAY 2 0 2009 <br /> SAN JOAQUIN COUNTY <br /> HNENLVIRONMENTAL <br /> ACCEPTED BY: V Lt J L EMPLOYEE#:03 2_1 DATE: -D O <br /> cl <br /> �1 <br /> ASSIGNED TO: t 0 EMPLOYEE#: r •-7 DATE: 5 -2-0 p <br /> Date Service Completed (if already completed): SERVICE CODE: O& % P I E: r2.3 i/ <br /> Fee Amount: 10-5, "a Amount Paid Payment Date OV <br /> Ito F <br /> Payment Type Invoice# Check# R ceive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />