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SAN JOAQUL..'OUNTY ENVIRdN VIF.NTAL HEALTH ;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 1 d '.x.81(!C •- <br />FACILITY ID # <br />BUSINESS NAM <br />tu'- -' -e -" <br />SERVICE RE VEST # <br />S �3(S <br />A <br />PHONE <br />fz-oy s7% s S0GEms. <br />zz(I <br />©( t (�f� <br />EMPLOYEE #: 032,f <br />OWNER/OPERATOR / — <br />{4 <br />/�jj /��/(� <br />ut�1{ `-(„(` <br />/CHECK If BILLING ADDRESS <br />FACILITY NAME; '. C-!ei <br />" '0 A <br />/7$It " <br />SITE ADDRESS <br />S"'j/ oo <br />Stmet Number <br />Diretm <br />µtE YAnSe/AL+ <br />io Ctt <br />ZI Cotle <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Amount Paid <br />-'�Street <br />Payment Date <br />Street Number <br />Payment Type <br />Name <br />CITY <br />STATE ZIP <br />PHONE #1T' <br />( ) q6-950 <br />APN # LAND USE APPLICATION # <br />[08—�c�o-f3 <br />PHONIER <br />( , ) <br />- BOIS DISTRICTLOCATON <br />LODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR C t.. R. OIC �. <br />1 1 d '.x.81(!C •- <br />.. 1` t �. CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />tu'- -' -e -" <br />PHONE <br />fz-oy s7% s S0GEms. <br />HOME or MAIUNG ADDRESS <br />Uo "o4 -stn <br />©( t (�f� <br />EMPLOYEE #: 032,f <br />FAx# <br />(Zo7) .53%-4.519, <br />CITY CE2 t^. C <br />Es U7 <br />/+ STATE 49 15 <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, ST and FED L laws <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPE TOA/MANAGER ❑ OTHERAUTHORizim AGENT 13 <br />I,fAPPLICANT 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. DAVMFNT <br />TYPE OF SERVICE REQUESTED: eUN-0 <br />"at–A ST'Fe— <br />RECEIVED <br />COMMENTS: <br />JAN 11 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />©( t (�f� <br />EMPLOYEE #: 032,f <br />DATE: I U, <br />ASSIGNED TO: <br />Es U7 <br />EMPLOYEE #: <br />DATE: / ('/6-7 <br />Date Service Completed (If already completed): <br />SERVICE CODE: L� 4, <br />P E:.3 . 03 <br />Fee Amount: <br />S C"') <br />Amount Paid <br />9 S O fl <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # '70yF <br />Received y: <br />'4D 48-02-025 <br />ISED 111172003 <br />SR FORM (Golden Rod) <br />