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May. 29. 2007 9:56AM No. 0491 P. 5 <br /> SAN JOAQUIN COYINTY ENVIRONMENTAL YTEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY lD# S RVIC[;REQUEST# <br /> Type of Business or Property , I 050 <br /> C245 SlIT/ �rn 6 <br /> OWNER/OPERATOR Cela <br /> Y\(.., CHECK If B LUN Ao ES Q <br /> Cela M 'YM <br /> FACILITY NAME <br /> SITE ADDRESS 1, 111 CI I C e <br /> StrealNuaibef DI cti re Ne <br /> HOME or MAILINQ ADDRESS (if different from Site Address) Sl et N s <br /> Sheet Npmbet <br /> ZIP <br /> CITY <br /> Exr. APN# j r ND # <br /> '(� `(��t <br /> PHONE#1 �✓.qI(;x"71 <br /> ( 1 SOS LOCATION CODE <br /> PHONE#2 EXT' <br /> ( 1 <br /> CONTRACTOR SERVICE RE+QUESTOR <br /> CHECK If B tLiN A RE <br /> FBusmtss <br /> FSTOR -E r M C� <br /> V <br /> PHONE# <br /> NAME �-�47r �, <br /> S FAX# <br /> HOME or MAILING ADDRESS , �� ( , ) <br /> STATE � ZIP oL <br /> CITY PIC siness owner, opel-fitol.or J <br /> BILLITI ACI�NO4VL>ED EM NTt s'ec fie ENvzRONM�NTAL 14EALTfi DEPARTMENT hourly the undersigned property or ba charges associated w'ltlT this uthorized 39CHt f Project <br /> acknowledge that all site and/or pro}ec p <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatiDndan and t��t;aws work to be performed will be done in accordance with all SAN JoAQv1N <br /> COUNTY Ordinance Codes,standards4EPA <br /> APPLICANT'S SIGNATIORE: <br /> DATE; <br /> 49- <br /> APPLICANT'S <br /> 'PROPERTY/BUSJnSSO\vNER❑ On/MANAGER ❑ OTPt)RAUTI{ORIZRDAGENr Tifte <br /> gAPpLIcAN7'rs not the�BCLLINoPAR7'Y-proof of authorization to sigh is require <br /> A�TIIOItIZATION TO RME�IVPXG PAR TYO 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 envavailable <br /> nmenta a Iteso assessment <br /> information to the SAN 10AQtJIN COUNTY ENVIRONMENTAL REALTH DEPARTMENT as soon as it is available a7ENVIROMU'rqCOUNTy <br /> nq�he same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTFD: <br /> COMMENTS; _v `t <br /> 1a cern�/t S Y7( o <br /> 1 J,J ,1 EMPLOYEE#: 03 Z,1 DATE: <br /> ACcEPTI50 BY. t v' C�-"C <br /> EMPLOYEE t/; q J�r_- DATE: �'- <br /> A$SIGNED TO: —T, an $pRVICECOD <br /> P i E; <br /> E: <br /> Payment <br /> .Y� <br /> Date Service Completed (if already completed): date <br /> Amount Paid29 / 0'� <br /> Fee Amount: 0: o rrRacelved Sy: �- <br /> Payment Type VIM Invoice# b t 3 � <br /> ` SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />