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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />0J <br />FACILITY ID # <br />�O% <br />COMMENTS: <br />(;e' e. �r� net, Vbc3/� <br />SERVICE REQUEST # <br />`IC�S�- <br />J SG� St.� )AtA)A <br />I <br />HOME or MAILING ADDRESS <br />SD r (e ell <br />5s <br />O R/OPERATOR <br />LO \ 1 �s 1 <br />CHECK If BILLING ADDRESS <br />t / <br />QO 1' r fG <br />FACILITY NAMEQC%Q 'l) G 'S <br />e� <br />SITE ADDRESS to 5-- <br />r-IIRONMENTAL <br />-�0/✓1 1 D/l t� <br />EMPLOYEE #: 3 2. <br />�oc, '�c/1 <br />/ sZ �7 <br />Street Number <br />Direction <br />street Name <br />Date Service Completed (if already completed): <br />CI <br />Zip C.de <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Fee Amount: ! s- a J <br />Amount Paid <br />s <br />Street Number <br />Payment Date <br />Street Name <br />CITY <br />Invoice # <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />\,2-9 ` <br />APN # ry <br />O &' — <br />LAND USE APPLICATION # <br />PHONE #2 Exr• <br />BOS DISTRICT } <br />Loc ION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR ///�Jt <br />lI <br />CHECK It BILLING ADORES S1:1 <br />1r'A�L Q�� <br />COMMENTS: <br />(;e' e. �r� net, Vbc3/� <br />BUSINESS NAMEff <br />// <br />we't%Ste/ 4 ei CAPa/ <br />PHONE# Ezr. <br />/ ,3 - OU ! <br />HOME or MAILING ADDRESS <br />SD r (e ell <br />. <br />FAX # <br />1 19 9-20 l6 <br />CITY(� I <br />o/ <br />STATE C ZIP <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 1 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 NO FEDERAL la s. <br />APPLICANT'S SIGNATURE: 4V('/41'r DATE: b -/t-OS <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ® OTHER AUTHORIZED AGENT El <br />/f 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: <br />COMMENTS: <br />(;e' e. �r� net, Vbc3/� <br />\ <br />lair deco^ <br />RECEIVED <br />3,a¢os <br />. <br />AUG 11 2009 <br />SAN AQUIN COU <br />r-IIRONMENTAL <br />ACCEPTED BY: Q 4 t <br />EMPLOYEE #: 3 2. <br />DATE: ! <br />ASSIGNED TO: ><0 O a Z .1 <br />EMPLOYEE #: 3 <br />DATE: 8 '1 O <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />I PIE: 9w-� <br />Fee Amount: ! s- a J <br />Amount Paid <br />s <br />Payment Date <br />"l <br />Payment Type <br />Invoice # <br />Check # <br />\,2-9 ` <br />Received By: �T <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />