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SAN JOAQUIrOUNTY ENVIRONMENTAL REALTT' ]DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />32 <br />COMMENTS: ' <br />SERVICE REQUEST # <br />S2o�D S -7-113 <br />OWNER / OPERATOR <br />FAx # <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />/ r <br />( ) <br />CITY a <br />STATE ZIP 991a <br />SITE ADDRESS <br />Street Number <br />E <br />Direction <br />Grdl,f /t r/) e III <br />Street Name <br />p'G <br />it <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />DATE:�r�A' 11,i' ENT <br />Street Name <br />CITY <br />EMPLOYEE#: <br />CMD_ D2 <br />STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />Fee Amount: ar a /O Amount Paid <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT• <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME%� <br />r/ D <br />COMMENTS: ' <br />PHONE# 3!—/i EXT' <br />��CC <br />Or MAILING ADDRES <br />FAx # <br />XOME <br />( ) <br />CITY a <br />STATE ZIP 991a <br />t <br />JUL - 1 2009 <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 or <br />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, S141E-arid FEDERAL laws. <br />APPLICANT'S <br />PROPERTY/ <br />l DATE: <br />MANAGER ❑ OTRER AUTHORIZED AGENT ❑ <br />If 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 envirai mental/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: S <br />!- <br />COMMENTS: ' <br />PAYMENT <br />RECEIVED <br />JUL - 1 2009 <br />SAN_ JOAQUIN COUNTY <br />ACCEPTED BY: - ,y <br />EMPLOYEE#: SC <br />DATE:�r�A' 11,i' ENT <br />ASSIGNED TO: <br />EMPLOYEE#: <br />CMD_ D2 <br />DATE: I fy <br />WWW <br />Date Service Completed (if already completed): <br />SERVICECODE: PIE: <br />Fee Amount: ar a /O Amount Paid <br />' p"0 <br />Payment Date ( O <br />Payment Type ✓ <br />Invoice # <br />Check # Lf I a <br />Received By: G� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />