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SAN JOAQUIN COUNTY ENVIRONMENTAL HF.ALTII DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK itBM.LINGAOrSR!~Ss� <br />SERVICE REQUEST # <br />,�Pn t -T)0 -J --a"' <br />PHONE # <br />� EXT, <br />HomE or MAILING ADDRESS <br />I (v3 =i <br />W <br />O>L>L V„ �, t.Jf� <br />=3 <br />CITY 1-� <br />STATEe57,0,- <br />(�D�20�� <br />OWNER 1 OPERATOR <br />CHECK if BILLING ADORF550- <br />FAC{urY NAME <br />Payment Date; <br />SiTEADDREss It <br />Payment Type l <br />Invoice # <br />-J t'x lit ct-J <br />-"-TS-32cn <br />Street Number <br />Ire on <br />5 t Name <br />C1 <br />Ti Code <br />hoME or MAILING ADDRESS (if Different from Site Address) <br />YNj <br />Rprpzl� <br />Street Number <br />Stroot Name 'T <br />CRY <br />STATE ZIP <br />PHONE #1 EXT'APN <br /># <br />LANA USE APPLICATION <br />PHONE #2 EXT. <br />SOS DISTRICT r <br />J AN <br />i <br />CONTRACTOR / SERVICE REQUESTOR <br />Rr=OUESTOR <br />"T <br />ACCEPTED BY: J 1, Z- <br />CHECK itBM.LINGAOrSR!~Ss� <br />BUSINESS N AME C�Gk="res c ItS�J <br />DATE: �/7 zozo <br />PHONE # <br />� EXT, <br />HomE or MAILING ADDRESS <br />I (v3 =i <br />DATE: �,-' ✓ Z DZ <br />FAX # <br />( :mac <br />=3 <br />CITY 1-� <br />STATEe57,0,- <br />ZIP <br />JTy <br />UT <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 ENVIRONMFNTAt, HEALTH DEPARTMENT hourly charges associated with dtis project <br />or activity will be billed to me or my business as identified on this form. <br />I also certif'v 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 Cortes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 1-^ DAF: <br />PROPERTY / BI SINE'SS OWNER OPERATOR J MANAGER ❑ OTHER At/TtIORizED AGENT ❑ <br />I,f APPLK:ANT is not the BILLING PARTY proof ref authorization to sign is required rirrr <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 JOAQUIN COUNTY LNVIRONMENTAI, HEALTH DEPARTIMENT 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: -<eVVegj �l r -► i }-� jC '' ve L 'C t <br />COMMENTS:t SCs/I�:"VPl,/ tnYi'ilJ}G�tXt3 c #7t r (T 1G 1 hon �0 a4 bo <br />ACCEPTED BY: J 1, Z- <br />EMPLOYEE #: <br />DATE: �/7 zozo <br />ASSIGNED TO: C� K <br />EMPLOYEE #; <br />DATE: �,-' ✓ Z DZ <br />Date Service Completed (if already completed): <br />SERVICE CDttE: <br />PIE: t <br />/at <br />Fee Amount: <br />Amount Paid; <br />-D <br />Payment Date; <br />Payment Type l <br />Invoice # <br />Received By: .._...- <br />EHO 48-02-025 SR FORM (Golder) Rod) <br />REVISED 11117/2003 <br />