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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />e- 67T� F-- ( <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />.n 911 Sti' SeAY_q€�-� <br />bvt cc7n't•'naes t� Do ,n7*G0\J <br />SEP - 1 2, <br />SERVICE REQUEST # <br />/Arco as S t -Q t, o n <br />HOME Or MAILING ADDRESS <br />-3f,yo 6epid cae"'(0r. Sv;-te 1?c7 <br />.3 P3 <br />FAX # <br />(/b) <br />d 0.5�f,..3 <br />OWNER /OPERATOR <br />STATE CC . <br />ZIP O <br />6P / west <br />Coasr Products <br />CHECK If BILLING ADDRESSO <br />FACILITY NAME <br />Arco <br />�i3c� <br />3 LI ,, (W <br />Payment Date <br />SITE ADDRESS7goG <br />N• <br />Invoice # <br />E/ 60rGdv StStoc-K*on <br />Clhec*.# <br />Received By: <br />9S�ly <br />Street Number <br />Direction <br />Street Name <br />City <br />ode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />(20) 9T7 ---2-9S`>-7 <br />©-? 17- j5o -t,, <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR eGndy Qf'Own <br />e- 67T� F-- ( <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />G of the r- - le `'G n I n t <br />.n 911 Sti' SeAY_q€�-� <br />bvt cc7n't•'naes t� Do ,n7*G0\J <br />SEP - 1 2, <br />PHONE# <br />(Wb)A1.?6 <br />EXT. <br />141? ol <br />HOME Or MAILING ADDRESS <br />-3f,yo 6epid cae"'(0r. Sv;-te 1?c7 <br />DATE: Q PPR <br />C DE <br />FAX # <br />(/b) <br />&31 <br />CITYcr V r t7V <br />STATE CC . <br />ZIP O <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operat rel Ng"W A§same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with t Is project <br />or activity will be billed to me or my business as identified on this form. SEP U 1 2009 <br />I also certify that I have prepared this application and that the work to be performed will be done i ithh'all SAN JOAQUIN <br />tftCOUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. M�N�1 HEALTH <br />APPLICANT'S SIGNATURE:, �«-- DATE:£/S7 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENTIaSefV.Ce / r.,nci5e%- <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: -7— <br />e- 67T� F-- ( <br />COMMENTS: Replace RGvity SenScPr <br />has not bten re.Picaced yet, <br />,Sensor awl- g10tr,M. <br />.n 911 Sti' SeAY_q€�-� <br />bvt cc7n't•'naes t� Do ,n7*G0\J <br />SEP - 1 2, <br />ACCEPTED BY: Q C-1 v 4:� t <br />EMPLOYEE #:Q '3 Lr <br />1 <br />DATE: Q PPR <br />C DE <br />ASSIGNED TO: c- <br />EMPLOYEE #: [� l�� <br />DATE: D <br />Date Service Completed (if already completed): <br />SERVICE CODE: O 8' <br />P 1 E: <br />Fee Amount: 3L1..; -9-i2- <br />Amount Paid <br />3 LI ,, (W <br />Payment Date <br />011k I <br />Payment TypeCr d.-4 d <br />Invoice # <br />Clhec*.# <br />Received By: <br />EHD 48-02-025 Cons n 62s17 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />9 <br />uNv, <br />Attv <br />