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SAN JOAQUIN CO X ENVI�ONMENTAL HEALTH DEPA 1+�- <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID# SERVICE REQUEST <br /> JkS 5fil l�(�� FA eco 044 5200-4 4 310 <br /> OWNER OPERATOR �O CHECK If BILLINGADDRESSll <br /> FACILITY NAME v SITE ADDRESScol <br /> vu-e✓ 1, 9 <br /> �erNmbar Irectlen <br /> Homrz or MAHJNGMunn of Different tram site Address) <br /> StreetNumger Street Ne a <br /> tFfrY STATE 21P <br /> PHONE#1 EXY, APN# LAND USE APPLICATION 0 <br /> } <br /> PHONE#2 ExT SOS aISTRIGT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR . i q n CHECK if BILLING ADDFt <br /> Eit <br /> �( �� <br /> BUSIliE55l1IAINEt, `(, " .� r PHO 4r CX t 7�' �Q6 <br /> Hopm or MAILING ADCIRESS 1=AX# <br /> . /��- t 4bF) of o <br /> CTT t V©S'G STATE B1' ZIP R�1 <br /> BII LL1�TG ACKNOWLEDGE14;t'E.1�tT: I,the undersigned property or business owner,operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific E1kMit0NtvlRAT3 4x HEALTH I>gpARTwNT 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 dons in accordance with all SAN JOAQ'UIN <br /> CouNrrY 0 durance Codes,Standards,STATE and FLDBRAL laws. <br /> A 14-WA <br /> APPLICANT'S SIGNATME: Il t" L' DATF.::t SAV <br /> PYto rY/BUSYNESS(�WCtER❑ OPERATORIMANAGER.❑ OTnmAUTHOYuzfinAGL'IT I� [ b�lQI,IC� dC�yf�1'Y1Ct� <br /> If APPLIC AN£is not the PILL M PARTi'proof of authorization to sign is requited Title <br /> AD')fp'RIZATION TO REL1 ASE INFOM,A' I 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 cnvironmentaUsito assessMent <br /> information to the SAN JOAQUIN CouNTx ENVIROI�:t *rrAL Ii>;ALT14 DE:PARTMEM as soon a4 it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICEREQUESTEp_ <br /> VILLivek <br /> ACCEPTED SY: Q�.6.0' ( � EMPLOYEE#: O3 Z DATE: <br /> ASSIGNED TO: EMPLOYEE#: $� DATE: (Q rz(05- <br /> Date S.ervlce.Completed (if already completed): SEM t E:2,309, <br /> Fee Amount: ..-2.-7'J-'00 Amount Pald 1,�p Payment Date 10/12105 <br /> Payrrlent7ype V lnvolce# Check# 78(o Received By: 4L- <br /> EHD46.02.025AyM%`$,4SFtM(Gaiden Rad) <br /> P <br /> REVISED 1111712003 R <br /> OCT 1 2005 <br /> SAN JOAQUIN COIJNTY <br /> ENVIRONMe"T ENT <br /> HEALTH DEPARTME <br />