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SAN JOAQUT`"COUNTY ENYHIONMENTAL HEALTH' FPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> O <br /> FACILItY NAME L9,dI Al 1? GSA <br /> SITE ADDRESS ��ll /� �/\� r� J�7} 1 ?p 37/ <br /> Street umber Direction 1" t ` me/1 " � ✓ f r/ <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 _ EXT- APN# LAND USE APPLICATION# <br /> ( 75 <br /> PHONE# BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 04 U CHECK if BILLING ADDRESS <br /> 1 LA 1. c� 7 <br /> BUSINESS NAME f ' ' E 1 ^ i WMM Qi C/r I I r P I�Jt � —/J�/ Exr. <br /> HOMEor MAILING ADDRESS /\+ C V FAX# _ <br /> (V5-) -/ <br /> CITY (f ' 2 STATE ZIP So <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,Standar ,STATE �ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; .Q <br /> PROPERTY/BDSiNESS OWNER❑ OPERATO MANAGER ❑ OTt�R AUl'FIORIZID AGENT V <br /> IfAPPLic,9NP is not the BILLING PA RTP proof of authorization to sign is required Tate <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 da(a 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: <br /> COMMENTS: RECEIVED <br /> APR 0 7 2009 <br /> SAN QUINCOUNFY <br /> OUN <br /> ENVIRONMENTAL <br /> HEALTH D r <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE 9: 0464- <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2'L PIE; �Z <br /> Fee Amount: ;g 0 a` Amount Paid a, O Payment Date Lk 1-710 CJ <br /> Payment Type Invoice# Check# b 4p Received By: <br /> EHD 48-02-025 t I ,I SR FORM(Golden Rod) <br /> REVISED 11/17!2003 DO <br /> 117 <br />