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11/23/15 11:52AM BZ Service Station Maintenance 916-57050 P.09 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST: <br /> Type of Business or Property <br /> I, BFACILITY ID#= # <br /> D ] <br /> SERVICE REQUEST <br /> VAI) <br /> I <br /> ONE <br /> RiOPERATOR' <br /> "I.- I ).j. CHEC9 If ,L �0: <br /> FACILITY NAME (�),-Ld §&&Q&2 <br /> SITF AWREss <br /> -2-2- q <br /> _91160_N—b., C Lj <br /> FHQ"MC or MAILING AODREss (it()jffera from Site r I c <br /> CITY UM Let- <br /> ITY !L --2lM0-NAMjL-- <br /> STATE zip <br /> PwNi#1 Gxr. � APN LMO USE APPLICATION# <br /> OW-;,-L- <br /> P-40NE 92 <br /> 7s&*DISTRICT LOMC�ATIQN CovE <br /> CONTRACTOR l SERVICE REQS. ESTOR <br /> RF-QUE$-roR <br /> -i?A 04LICK If-OA <br /> BUSINLL'88 NAME <br /> EXT, <br /> HOME or MAILING A D-D-RE$$--"--� rr <br /> FAx# <br /> —7T—---------- <br /> CITY T Y STATIER <br /> LL <br /> AS,KNOVI AM-99-M-E.M; 1, the undersigned property or business Owner, <br /> Operator or allthoriZed aget of some, <br /> acknowledge that sit Site and/or PrOjOct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charg n <br /> activity will be billed to me or my business as identified on this form, es asr-ociated with this project of <br /> 1 also certify that I have Prepared thisappjtc9tj / <br /> COUNTY ordinance Codes,Standards,$T�lr� on and'y.�, 18 work to be performed YAII be done in acCordonce with all SAN JOAQUIN <br /> ,land EOtVAL la , <br /> APPLICANrs SIGNATURE <br /> DATe; -4 <br /> PROPERTY aUSINess OWNIEEIR[3 RATolt 0 OTHER AuTHOWZeo AeENT-b <br /> If APPLICANT IS not ffie ftLNS PAR rY.Proof of a uthorizO 0017 to Sig"Is required riot., <br /> - INFQBM8112N <br /> Site address, hereby authoriz o : When applicable, 1, the Owner of operator of the property located at the above <br /> 0 le release of any and all results, geotechnical data end/Or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY EivviRONIVIFNTAL HEATH DEPARTMENT as soon as it is a : <br /> my representative, vallable and at the same time it is provided to me or <br /> -Fff®r I M -917- <br /> TYPPOWWREQUESTED, <br /> NOV 2 3 2015 NOV 2 3 2015 <br /> SAN JOAQUIN couNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT ENVIRONMEN" AL <br /> HF:AlTi4 n1ZPAQTAAl= IT <br /> AccEPTED By, <br /> EMPLOYre DATE. <br /> AsSIONED To, r <br /> n EMPLOYEE <br /> DATE" <br /> Date Service Completed (If already completed): <br /> SIRVI61!CODE: PIE <br /> z <br /> 7- <br /> Fe;A u <br /> Amount: �=AZio P:.�, <br /> Amount <br /> 0 Payment Date <br /> Payment Type invoice# Che # " <br /> -7; <br /> ocelved By-, <br /> iM71?T <br /> (THO 46-02.025 <br /> 07/1710$ SR FORM(Golden Rod) <br /> ............................. <br />