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+, SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTH 1JEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />55Z <br />COMMENTS: <br />SERVICE REQUEST # <br />5-900&0(IS5-- <br />OWNER /AbPERATOR <br />' <br />CHECK N BILLING ADDRESS IT <br />FACILITY NAME <br />r-- <br />SITE ADDRESS/ 1-5-11 <br />sj/ <br />St2N. N_r.', <br />- - �G ✓/y!'?// <br />/� qs <br />Zi Cde <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />En. <br />Street Name <br />CITY <br />y <br />EMPLOYEE M / „ '7 L' <br />STATE ZIP <br />PHONE#t <br />EXT. <br />APN# <br />LAND USE APPLICATION# , <br />PHONE#2 <br />( I <br />Ear. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />- E .&JED <br />COMMENTS: <br />JUL - 9 2010 <br />CHECK N BILLING ADDRESS <br />b <br />SAN <br />ENVIRONMENT <br />DEPARTMENT <br />BUSINESS NAME <br />Ex <br />HEALTH <br />PHONE# <br />En. <br />DATE: 7 IIA <br />oaya« <br />y <br />EMPLOYEE M / „ '7 L' <br />r <br />a/3- 1;1 7 <br />HOME or MAILING ADDRESS <br />SERACE CODE:' <br />2 <br />FAX# <br />Fee Amount <br />Amount Paid <br />3 O _ <br />Payment Date <br />"I I / D <br />Payment Type <br />CITY <br />Check # � S 3 <br />STATE /�� <br />"P <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 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, STATE end FEDERAL laws. -y <br />APPLICANT'S SIGNATURE: rte. DATE: X —gyp <br />PROPERTY/BUSINESS ORLASE'INFORMATION: <br />PERATOR/MANAGERLJ O'CHERAUTHORmco AGENT❑ <br />fAPNIitheB/LL/NGPARTY, proof of authorization to Sign is required Title <br />AUTHORIZAT When applicable, 1, the owner or operator of the property located at the <br />above site a authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />inforrnatio AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided,0 N epresentative. nG 11 <br />TYPeb, VI QUESTED: 6 <br />- E .&JED <br />COMMENTS: <br />JUL - 9 2010 <br />SAN <br />ENVIRONMENT <br />DEPARTMENT <br />HEALTH <br />ACCEPTED BY <br />EMPLOYEEM <br />DATE: 7 IIA <br />ASSIGNED TO: ` x�zA <br />y <br />EMPLOYEE M / „ '7 L' <br />DATE: <br />Date Service Completed (if already completed): <br />SERACE CODE:' <br />2 <br />P / E: 3 6 02 - <br />Fee Amount <br />Amount Paid <br />3 O _ <br />Payment Date <br />"I I / D <br />Payment Type <br />Invoice # <br />Check # � S 3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />