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07/02/2008 WED 12: 13 FAX -- - - - <br /> 07/02/2008 WED 11: 58 FAX 20433 SJC EHD ^b <br /> ----.....-____ ....__.__..._.__...___.._—_......SAN-JOA7QU1N-COUNTY-ENVIRONMIZNTkCfJF flH-DEPARTMENT <br /> i <br /> SERVICE REQUEST <br /> i Type of Business or Property FACILITY IDA SERVICE REQUEST# <br /> �.L'l-(LCL k 0';D `.':>fne tl-�-tI <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE <br /> rrA//D��DRESS /I j_', .✓ <br /> Wumber Dimmlo / a Cil ii C.d. <br /> 1 <br /> HOME Or MAILING ADDRESS in Different from Site Address) <br /> -c-k-S svwl Numear veal oma <br /> CRY STATE zip <br /> ( v c?4-cd a c-L: D G <'7, ; <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (1% ) 9-70 35007 <br /> PRONE#2 E%r• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ♦' � / /) 'ter// p s CHECK if BILLING ADDRESSE] <br /> vlili F,•t' `<?.1/✓[L:C l.J�aG UG44E.7 t mop% <br /> BUSINESS NAME PHONE# E%v <br /> HOME Of MAILING ADDRESS FAX# <br /> STATE ZIP <br /> CITY �✓, �, W-r-/• .rMC'-I � . ��t <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> -------- acknowlettge"tkat'all-site aod/or ploJec[specific�ENVfRONFfGNT'ACHE,A1:TIdDLPAliTMLNT If6uPly Chai'ge3 a£5ocla-ted wdh this projeC[ <br /> or activity will be billed tome 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,Slandards,STATE andFEDERALtaws. <br /> APPLICANT'S SIGNATURE: % -- DAT,E�:,{{ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE R ❑ OT'nBRADTIl0RIZEDAGF,N'r q51 t(Y/FTtkJ< YtJ4' •^Jr.��.t.:-I' <br /> 6(.4PPuceNr 1S not the l3rturvG PART praaf of aHBtaritalion to sTgn iS rer/rdred rift <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 environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT aS Soon aS it i5 available and at the same time it 15 <br /> provided to me or my representative. V`( <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JVpS 0 ?QOtI <br /> ATH Pf <br /> MF <br /> HPARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEEM ZZ :d DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: V 1 PIE: ;7pW <br /> Fee Amount: o'" Amount Paid a y a� Payment Date 2 S g <br /> Payment Type V/� invoiceiv Check it L Received By: <br /> -------- EHD48-02-025 - - - SR FORM(Golden Rod) - <br /> REVISED 11/17/2003 <br />