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SAN JOAQACOUNTY ENVIRONMENTAL HEALTAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />1Z <br />SERVICE REQUEST # <br />&asoline 5}ati017 <br />000 ICA <br />3% <br />5 '�"' <br />OWNER / OPERATOR <br />�r'buP lnc. <br />CHECK If BILLING ADDRESS <br />p,t� T <br />CH EvtzoN F7F5PU T'b <br />60• <br />HOME or MAILING ADDRESS <br />134o Arnold <br />Drive 5uite 110 <br />DATE: /l 2-7 DL -f <br />FAX# <br />(925) <br />FACILITY NAME *2-o-3117 <br />CITY mari'ince <br />SITE ADDRESS755 <br />S•�I/�• <br />Amount Paid 2-741 rUC> <br />Payment Date Z 2 l) Lf <br />Tracey <br />g5374 <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT• <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />/ SERVICE REQUESTOR <br />REQUESTOR • • <br />Retrof 17 Plan Ghack <br />1Z <br />CHECK if BILLING ADDRESS <br />e,0Mtaitnr d nt reQlace1+n1C��'. <br />�u L <br />COUNT <br />SAN 30N -of <br />R� <br />NEA�TN <br />ACCEPTED BY: V w—, <br />BUSINESS NAME <br />B <br />�r'buP lnc. <br />DATE: Z b� <br />PHONE# <br />q2g <br />EXT' <br />313 °100 lb} <br />HOME or MAILING ADDRESS <br />134o Arnold <br />Drive 5uite 110 <br />DATE: /l 2-7 DL -f <br />FAX# <br />(925) <br />313 - <br />CITY mari'ince <br />STATE CA <br />ZIP 11455 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator oiCauthorized agM oo 'same <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associate with ttiis 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. laws. <br />APPLICANT'S SIGNATURE: /': =L ���.w DATE: 7 - Z <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR AJ.'VNAr.LVE3 OTHER AUTHORIZED AGENT M MA.-/-+ 62—rAoQi <br />If APPLICANT is not theBiLLiArGPARTY 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 availab1`5giTsame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Repair <br />Retrof 17 Plan Ghack <br />1Z <br />COMMENTS: Plan GVld4k fnr grill <br />e,0Mtaitnr d nt reQlace1+n1C��'. <br />�u L <br />COUNT <br />SAN 30N -of <br />R� <br />NEA�TN <br />ACCEPTED BY: V w—, <br />EMPLOYEE #: 3 1', <br />DATE: Z b� <br />ASSIGNED TO: j <br />EMPLOYEE #: Q <br />DATE: /l 2-7 DL -f <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: 2 3 <br />Fee Amount: 'Z -74!5;1,r 00 <br />Amount Paid 2-741 rUC> <br />Payment Date Z 2 l) Lf <br />Payment Type ✓ <br />Invoice # <br />Check # g'p D 113 9 <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />