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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACA.ITY ID p SERVICE REQUEST 9 <br /> OWMN <br /> �. <br /> FAcam NAstE C �.-�-�1"�1 <br /> SITE AM= -/C 17�6u <br /> _/ 1 I [ms <br /> Hpme Or MAwrod ADDFM (N DMN rent from SM AddTe") <br /> 5 Nwnaa stre.t <br /> STATE aP <br /> Clay <br /> PnatlE#) FX, APN0 LAND USEAPMu TIONIF <br /> ( l <br /> Pe0NE 42 W. BOS[MTnILT r acanopp OoDe <br /> 1 <br /> CONiiItACTOR/SERVICE REQUESTOR <br /> REpq - CHECK If t3uiNa ADDRESS❑ <br /> BuslNM NAW PIIaEC a`r. <br /> � 77D <br /> PAr# <br /> HDME or NIAIlJI/0 <br /> STAT: .� aP ,S'�toJ <br /> Cm <br /> Mt,LING WLEDGEME : L rhe undasiped property m b isinms Owner, operator or mtharizM "t of some, <br /> acknowledge that all site ander Project specific Bt vm0NMMTAL HEALTH olzpARTMENT hourly charges associated with this Wjecl <br /> or activity will be billed to me or my business as ideMifform <br /> .1 <br /> en this fo . <br /> I,also certify that I have prepared this application and tblat the pork t0 be performed will be done in acwrdenoc with all SAN,tOAQU N <br /> ('AUNTr Or)omancc Codes, Vandg\6s, TAim and FE1112r f <br /> PPLiCAN rS SIGNATURE! �a -+—- l�/Ibpp�� DAM <br /> y Q <br /> / PR[wsaTV I BUaNICSs vxNrAb] OPCr1ATOR I MA Wt/-1-1 OTaRA AtrtttORifG4 AGa[rr❑ <br /> !f APPIJGM'Lr nal rhe L!N 1'd6Z~,'P�//f of to sign b r"tared r:rpr <br /> A mHOR?ATiON TO RELEASE 1NF0abjApONt WAD applicable,1,the DTrner or OPeratw of the Property IDadw at the <br /> above site.. address, hereby mghmi= dw release Of any and all rmfts, geotodMICal date and/or envirmnemxlfsBe assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMEMTAL HEALTH DEPARTMENT as SON M it is available and at the same time Ir is <br /> provided to Poe or my mMesgnWve. — <br /> RECEIVED <br /> TYPE Dr SERVICE RtgllEfRFD: <br /> CoarnNrz � P) ►^q I U Dc, CJI/t �/�`0—r r 2 1 J <br /> 1 �J SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> AIGGL�I8161': FJePLDrEE ilt: DATE: <br /> AmamEu ro: EtsPttlYff DATE <br /> Date servke CaMpk46d (H abmary eerrrplawd): <br /> p�A�0„r "` Amount Paid U Date LA Z I <br /> Payment Type l/ Invoke R cbeck g y � \ Reciived By: Nr, <br /> EHD 49-02-025 Sit FORM(Golden Rel) <br /> REVISED I V17/2003 <br /> 000(8 YV3 9V:Z0 LTOZ/BO/ZO <br />