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SeV ,23 2008 10:01RM Slun=iker Construction 951-788-7089 P.5 <br />t <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE[)U ST <br />Type of Business or Property FAC1LM ID # <br />SERV ff REQUEST # <br />l mer e /C s -/e 11�r S <br />l_ <br />OwmEft / OPERATOR <br />V_e .c o%; �.o o <br />, <br />L d r<YS r% a-a� �L <br />Cr+aen N BII IINp AOOrteBs ❑ <br />FAOLITY NAME , <br />,L J V <br />SEP 2 3 2008 <br />SRE ADonss 'er" <br />� � � <br />�r/Qo/'►% <br />� r�� <br />rVum r <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />1`10MIE Or MAIUNG ADDRESS (ii Differerd from Sfte Address) <br />EMPt.CYEE #: <br />/Olca� Al - <br />A6sx;NED To: / / <br />Cry ,r-� / f <br />STrtti1E LP-� 3' <br />PHONE 1111111 Exr. <br />f Port 3 <br />APN <br />I. USE APPUCAT1oN S <br />PI+oNEtit Em <br />am DWTFdCT LOCAPON CODE <br />"Y-L'N 1 KPIC., 1 UK 1 NLKVIft:E REQUESTOR <br />RECX STOR <br />r / �C� •�'l.A� C#W" it DIUNO AWFMU ❑ <br />Bus*w= NAMIE y PHONE # EXT. <br />At e <br />HouE or MMiumG AmREss FAX # <br />�a67j-- .l" .4 v (Qr ) Y8-70 <br />crnr K I'edr >~ r✓ STAT C ZIP43v i <br />mh&w Esq au.aL�n�.�JJasLML'.1V 1: r, Inc unaeersygned Property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HE,a1,TH DEPARTMENT hourly charges associated with this project <br />Of 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 than the work to be performed will be done in accordance with all SAN JoAQUIN <br />COUNTY Nuance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: '0/— 2 .7— C) � <br />PROMRTY 1 BtSlNgss OwNEg❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED ACCNT <br />4(APPL ICANr is not the BILL ; , PARry. proof of arudeorftahiou to S$)gw is req a&Wd rate <br />AlJTHORI2ATION TO, RE1,EASE 1 YFORM�A'I'ION; 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 enviromnental/site assessment <br />information to the SAN JOAQUIN COUNTY ENv1RONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me br my retaesentative <br />TYPE OF SERVICE REQUESTED: <br />DAYM E N T <br />CaieiENrs: Fu ^v c , s j O . L <br />V_e .c o%; �.o o <br />qr1-1 60.44. C a �� v.v-..► <br />SEP 2 3 2008 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPt.CYEE #: <br />DATE: <br />A6sx;NED To: / / <br />EMPLOYEE 1k <br />DATE: <br />Date Service Compleu d (ff aleawly cam~): <br />SERVIeE Cool_:P <br />f E: 2 <br />Fee Anmmnt: Z .5-0 <br />Amount Paid [� 7�- �Z� <br />Pa Dato <br />Payment Type b"ice # <br />Check # <br />Received By: <br />u . , <br />EHD5 SR FORM Golden Rod <br />REVISED <br />11/ 11/17/2003 ( % <br />