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EPARTMENT <br />SAN JoAQ oUNTY ENviRONMENTAL HEAL'1 1 <br />SERVICE REQUEST <br />Type of BuSlneSs or Property <br />FAC�IiY ID SERVICE REQUEST # <br /># <br />County owned Facility <br />OWNER / OPERATOR <br />FAemirt NAME SJC Jail Facility <br />SITE ADDRESS Michael <br />7000 street HUM* K Dry <br />HOME or WWUNG ADDRESS (If DWerem from Site Address) <br />CITY <br />PHONE #1 <br />PHM#Z <br />REQUESTOR <br />HOME Or MAILING ADDRESS <br />2370 Maggio Ci.r. #4 <br />CITY Lodi <br />Err. I APN # <br />En. <br />=4 <br />—0-&—d' ( <br />SP.c�C j�iU 1 <br />i7-AN"A"D 2 CHECKifBILUNGADDRESSO <br />STATE ZIP <br />LAND USE APPLICATION # <br />SOS DISTRICT <br />CONTRACTOR / SERVICE REQUESTOR <br />Inc. <br />LOCATION CODE <br />CxECKifEN ADORESST� <br />Exr. <br />367-4800 <br />367-5424 <br />ZIP 95240 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or n 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 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 JoAQuuJ <br />COUNTY Ordinance Codes, Stmrdards, STATE and FEDERAL laws. <br />��y,, / <br />Kms" ,.� DATE: <br />A.PPLICANT'S SIGNATURE: Contractor <br />PRoreRTY / Bosmm owi� =13 OrilitA OTHERADTHORiZED AGENT L7 <br />IfAPPLtCANT is not the BIL, , ANG PARTY. proof of tudlror on s ,n is required Title <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 environmentallsite 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: / '� t"rU r I I <br />COMMEM. Remove malfunctioning LATS - 1 Liquid Sensor and replace with n P <br />_D <br />ACCEPTED BY: <br />EMPLOYEE #: <br />ASSIGNED TO: EMPLOYEE M 4 <br />Date Service CompleteR'Invdice# <br />leted): SatvlcE CODE: <br />Fee Amount: Amount Paid Qi? 019 �. O L) PA <br />Payment Type Check # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />JAN 4 2008 <br />'AN JOAQUIN COUNTY <br />Al <br />LT D <br />DATE: <br />PIE: - <br />'7 O� <br />Datel O <br />Received By: <br />SR FORM (Gorden Rod) <br />