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a <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />RERVICE REQUEST <br />r;N.�raess or Property FACILITY ID # <br />GDF �`� �� <br />�: <br />OWNER* OPERATOR B S Angle <br />FACILMY NAME Mirimar Valero <br />I, SITEADDRESS 1605 S I EI Dorado St <br />Street Number Direction <br />l '4F or MAILING ADDRESS (If Different from Site Address) <br />PHONE M <br />PHONE #2 <br />" APN # <br />EXT. <br />SERVICE REQUEST # <br />d 3001" <br />CHECK If BILLING ADDRESS <br />Stockton95206 <br />Ci Zip Code <br />Street Name <br />STATE CA Zip <br />LAND USE APPLICATION # <br />LOCATION CODE <br />CONTRACTOR / SERVICE "Q U 1 NT0K <br />REQUESTORINS L-6 CHECK if BILLING ADDRESS <br />BuSINESS NAME _� ` � /_ _ _ PHONE# Q � � � Ct Q <br />FEOME Or MAILING ADDRESS vA AJ p - ' (�G 4 a <br />�""C � r 1 � rt' Ir.Iv 'v <br />CITY J C��/�C- M O N T-- STATE CA ZIP Ct k, " <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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar E an EDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: `: < <br />PROPERTY/ BUSINESS O OPERA OR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLiCANT is not the BILLING PAR 77 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 J EALTH DEPARTMENT as soon as it is available and at the Same time it is <br />provide or my representative. _ T <br />OFSERVICEREQUESTED:°��T T�DtT _ RECEIV <br />t:ommENTs: 5/2712011: Replaced 87 STP relay discovered during annual monitor certification:.. JUL 1 9 20 <br />SA �NVI RONIMENTUIN COUA <br />ACCEPTED BY: Ce <br />EMPLOYEE #: gCSf <br />EMPLOYEE M TZ) <br />DATE: <br />ASSIGNED TO: (�J� <br />DATE: 7 / <br />Date Service Completed (if already co -t d): 5/27/11 <br />SERVICE CODE: <br />PIE6 <br />Fee Amount: do Amount Paid 3 p-® <br />I Payment Date -? <br />Payment Type ✓ <br />invoice # <br />Check # 3-7 p <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />