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03/22/2012 06:17 0000000000 0�1`_���E`t`t`_��!`���ON PAGE 07/30 <br />SAN JOAQUIN COUNTY ENVIRONMENTMr HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FAC1I.tTY ID # <br />��3'1 SERVICE REQUEST # <br />OWNER / OpDRATOR C' U ' \ cc `�-' y IC' <br />i V`?II PC,C-c- l/E�Ccs �iu CIKF.CKifBI INCA ES <br />FACILm NAME UC I i <br />?QCi�c�Z 1'itjl�ej /r�t� C�ivC�10�L <br />SITE ADDRES$ <br />si'GG{�Y� q.SI?A(v <br />Street NU er Dl <br />t <br />OME or MAILING ADDRESS (If Different from Site Addreaa) '— rCITY Number 5 rest N n <br />S�e.�C.�o►-� srAre:C� zla yS—Z6 <br />PHONE #1 ExT. <br />APN # <br />(Z.y) S S3 LAND USE APPLICATION # <br />�� r3 <br />PHONE # EXT, <br />( ) BOS D13TRICT LOCATION CODE <br />Ra=QUESTOR CONTRACTOR � SERVICE .REQUESTOR <br />U 5� iIMM` /JCNECKINUL-I1VCAODRES9 <br />BUSINESS NAME / PHONE # EXT <br />iiOME or MAILING ADDRESS r, FAX ft <br />C / <br />Flux 610 (C'.61 9Z33 <br />CITY STATE zip <br />S114f,ING me, <br />ACKNO3yLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of S9 <br />acknowledge that all Site and/or project specific ENvt1tONMENTAL HIiALTFJ .DEPARTnar1NT 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 and FE vys_ <br />APPLICANT'S S.IGNATUR,)6. <br />DATr:,: <br />PROI'RItTY/$U9INRSSQvylvgR❑ pPt ATOR/MANAGER OTIIRRALI73�OR1?.¢DAOENTD�a�.Li <br />IfAPPL TCANT is not the 131[.IING F 7y ren o authorization to si —• <br />P 1 f gn is required rtrTe <br />AUTIiOR1 ATfON O REI,EAS)v IN ORMATfON; When applicable, 1, the owner or operator of the property located at the <br />above Site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQ11IN COUNTY ,F,NVIRONMhNTAL I'1:EAL77-I DEPARTM.gN7 as goon 0.S it is available and At the Same time it is <br />provided to me or my representative, <br />TYPE OF SERVICE REQUESTED: 4 <br />PAY ME <br />COMMENT9: ID <br />MAR 2 2 V12 <br />� rMR E�TMENT <br />H�TM <br />ACCEPTED BY: EMPLOYEE: DATE: <br />ASSIGNED TO:4r" co� EMPLOYEE #; <br />J y2— DATE: <br />Gate Sprvice Completed &allready completed): SERVICE CODE: I <br />P1 E: <br />Fee Amount: c1 o Amount Paid Payment Date <br />Payment TypeAInvoke # <br />I Check # <br />Re eived By., <br />EMD 025 <br />RCVI$ED SED 1111712003 SR FARM (Golden Rod) <br />