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5AN JOAQUIN I:UUN'I T Lt N VIHUNMEN'IAL IiP;AL'I'H ULPAH'1'MENI' <br /> SERVICE REQUEST <br /> Type of Buslnese or Property FACILITY IDA SERVICE REQUEST/ <br /> Sievv �39s� <br /> OWNER/OPERATOR <br /> 't tYl A(=I t_i N E&£IR, CHECK N BILLING ADDRESS <br /> FActrrY NAME E-C'f-fa- PRopElZ-Ty <br /> \ SITE ADDRESS 2c1 0 a o 1 tJ. I M AC. V I LLE iZD . <br /> cLE:rnCnri-S 9'Syz'4- <br /> Sb tNumbert Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) 17-115- E• PEt_-r I E2 7Z-'::' <br /> rest Number Stwt No" <br /> CRY A(--'A6LPO STATE CA ZIP `/SY20 <br /> LI <br /> PHONE Al e"T APN a LAND USE APPcAnoN A 1 <br /> ( Zoy ) 004o& P1k-11007-11 <br /> PHONE#2 Ear. DOS Dtamicr LocAnoN CODE <br /> i q( ) l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST�DR A.13$14 h•CC [7 <br /> CHECK If QILLING AooREsa❑ <br /> BUSINESS INAIME t-L v E OAK— PHONE! err <br /> 4071 3e`7-1>3 35, <br /> HOME or NIAIUNG ADDRESS y O—+ WFA%# <br /> orrlc 5-r-. tZa'I13�9-03'�--} <br /> Cm LO•D 1 STATE GA ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQu1N <br /> COUNTY Ordinance Codes,,Standards,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE:: I—J.01 — \ <br /> PROPERTY/BUSINESS OW ER OPERATOR/MANAGER OWER AUTHoRuxD AGENT E3If APPLICANT is not the$ILIJNQ PARTY.proof of anthorizadon to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /24EV 16 W SOIL S U ITA 731 L—I Ty 9,rL rb\/ <br /> t:OaaENTs: Z!�/�� l-z�c / r ( RECEIVED <br /> (l.6�612-1 firs. - , DEC - 2 2011 <br /> 1RONMENrAL <br /> OUNTY <br /> grALTH DEPARTMENT <br /> ACCEPTED BY: L L V 1_i t? EMPLOYEE A: U 2l. jar DATE: (2—(47( <br /> 2 ( <br /> ASSIGNED 1'0: ESC.C�� { Ewuoyeie A: SqE DATE: I,q 24(( <br /> Date Service Completed (if already completed): SE"MCOW. a PIE '9( a <br /> Fee Amount: 2 S(' Amount Paid 7000 Payment Date 1 <br /> Payment Type C'Akk Invoice d Chock/ Reclived By <br /> EHD 4"2-025 SR FORM(Gowan Rod) <br /> REVISED 11/17/2003 — <br />