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SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTAPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />F(ACIIIL(XIITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />0611S `!c1 N1C1,Y Ket <br />(209) LRP I <br />CITY t-fDa---F-„n <br />ZIP 615/j05 <br />STATE Of - <br />OWNER/ OPERATOR <br />EMPLOYEE #: <br />DATE:AC—vI <br />CHECK BILLING ADDRESS <br />P0. y 1� I <br />I 5 il- hn <br />If <br />FACILITY NAME <br />Amount Paid 3 S �1 D <br />Payment Date <br />(v <br />SITE ADDRESS i�33 <br />tr. <br />n , <br />v'icfor kd. <br />Check # ! ro '?� ' <br />(_C�C�i <br />�rj2,40 <br />Street Number <br />Direction <br />Street Name <br />Citv <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />v i Gfib l <br />c)?)G <br />J)am°Lv l dv r <br />Street Number <br />Street Name <br />CITY <br />Ind i <br />STATE ZIP 3 <br />r <br />PHONE #1 EXT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />if�j -13t/ n{J n tractor-s <br />(J <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME r <br />I t� ]OT <br />COMMENTS: <br />PHONE# ExT' <br />(20) <br />HOME or MAILING ADDRESS326 <br />5 .vv . war m Dr. <br />(209) LRP I <br />CITY t-fDa---F-„n <br />ZIP 615/j05 <br />STATE Of - <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: kaxi' — , lu6A*DATE: 28 I o <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® Pno re VPi <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 />�T <br />TYPE OF SERVICE REQUESTED: Lt-sS % <br />13FICEIVED <br />COMMENTS: <br />MAY 282010 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: v f 'f ,- <br />EMPLOYEE #: 3 <br />DATE: 2� rZ1 <br />ASSIGNED TO:i <br />EMPLOYEE #: <br />DATE:AC—vI <br />Date Service Completed (if already Completed): <br />SERVICE CODE: tf <© l <br />P / E: �ai <br />Fee Amount: 3 vo <br />Amount Paid 3 S �1 D <br />Payment Date <br />(v <br />Payment TypeInvoice <br /># <br />Check # ! ro '?� ' <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />