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SAN .TOAQ U1 OUNTY ENVIRONMENTAL HEALTHPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />t t <br />FACILITY ID # <br />n (J L-✓� <br />SERVICE REQUEST # <br />ASC Ga S-rQt"`On <br />3(x,32., <br />1 5 2009 <br />,S'V2-ous8331 <br />0 -s <br />HOME or MAILING ADDRESS <br />3111c i5old Cqt-iP r. ✓:Ie. 170 <br />FAx # <br />(9/6) <br />631- 13/7 <br />OWNER / OPERATOR <br />STATE COY <br />ZIP <br />ACCEPTED BY: O L L/ I <br />7' C S -r Pro8ucts <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: B A -C Y -LLS <br />A c-0 <br />213 0 <br />Date Service Completed (if already completed): <br />SITE ADDRESS 7 7c 6 <br />N. <br />( I> o rC. C) v S 7 rcei <br />P 1 E: <br />5 t O� K t0� <br />y.5'.21 U <br />S//treat Number <br />Direction <br />StreetName <br />Payment TypecreX i C4rd <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT• <br />APN # <br />3sc) <br />LAND USE APPLICATION # <br />(2a$ CIS 7- 2987 <br />D -- -16 <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />S 11/ <br />LOCATION,CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1 G <br />RCI <br />t t <br />CHECK If BILLING ADDRESS <br />n (J L-✓� <br />p <br />:rN S7 'ri SVM/O. L LVIe /EQ <br />BUSINESS NAME <br />ettlet" 2 con )mac • <br />1 5 2009 <br />PHONE # <br />/6 <br />EXT. <br />82 682Y <br />HOME or MAILING ADDRESS <br />3111c i5old Cqt-iP r. ✓:Ie. 170 <br />FAx # <br />(9/6) <br />631- 13/7 <br />CITYOo n ch Cordovci <br />STATE COY <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, 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 DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER [3 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Pr, 5)(21-V.'Ce. &-i-gng.3e r <br />If APPLICANT is not the BILLING PARTY. proof Of authorization to sign is required 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: L.LS T <br />t t <br />COMMENTS: 2ePIaeG iQVItn Sensor <br />p <br />:rN S7 'ri SVM/O. L LVIe /EQ <br />1 5 2009 <br />SEP <br />SAN JCA �NMEN Al. <br />ACCEPTED BY: O L L/ I <br />EMPLOYEE #: 03 2 / <br />DATE: O p <br />ASSIGNED TO: B A -C Y -LLS <br />EMPLOYEE #: [-(P 3 V <br />DATE: t � <br />Date Service Completed (if already completed): <br />SERVICE CODE: ) 9 <br />P 1 E: <br />Fee Amount: -3,15- Do <br />Amount Paid <br />-3 '-Is m� <br />Payment Date <br />cifiY109 <br />Payment TypecreX i C4rd <br />Invoice # <br />I <br />C*eekfl►- <br />Received By: <br />EHD 48-02-025 �n�• 3971 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />