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02/20/2008 WED 15:26 FAX 2094683433 SJC EHD -•-- Stockton Sery Sta Lq Co <br />r• . • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTh1 DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />L -4A32 <br />51g-0 <br />NER OPERA 0' <br />CHPCK If 1 LIN <br />FACILITY NAME <br />SIZE ADDRESS j'1 /�,,, <br />2.3 _truer Numu�r D"uttfo �trur l No.o _ i Cit v Code <br />HOME Or MA!UNG ADDRESS (If DlHorunt from Silo Address) <br />Streol Numb r Strout Name <br />CITY STATE ZIP <br />LAND USE APPLICATION Y <br />�I ) <br />' PHONE 921 — Exl• SOS DISTRICT LOCATION CODE <br />_ CONTRACT _ /SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />BUSINESS NAM /' _ PHONE _�r'33 Exl. <br />Cses (� [ <br />HoriE or MAKING ADDAESS �' _ r Ffx _ <br />dV Ub/UUo <br />.[`X'�"ri�3✓ --- STAZIP ICA <br />! V / <br />BILLING ACKNOWLM,DGFIVIENT: I, the undersigned property or business owner, operator- or authorized agent of same, <br />acknowledge that all site and/or projeCt SpCCIfIC LN\•ut0NMI;Nt':,I. HEALTH DITARTMENI'hottily charges associated with this project <br />c�r actirity wili be billed to me or ray business as identiNd on this form. <br />1 :uw ccrtily 11m7 I have prepared this application al thy the work to be p orifled will be done in accordance with all SAN JOAQUIN <br />CO3,aNi1 tR;(hulaceall <br />�PPLi� :1N'l''S SlCNr�'fURE: DATE:. % O Z9' <br />I'RuttHrv; 6,.sl�ts:Uw:Nr:t:� OPERA1014 -1ANAWA D 01,4,Av1 101(lzri)AGEN-r❑ <br />not the!{IL1.l;yt; I'aitn; prooj(f atilhorizarion io sign -is regWred Title <br />AU1110RIZAT10IN TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at Ute <br />Abu%c sit. addrvs:i, hzleb) authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information 10 OIC SAN JOAOUIN COUkIY I NVINUNMENT•AI. HFAI.TI'I I)RPARTMF.NT as soon as it is available and at the saint time it is <br />provided to int: or Inv representative. p <br />TYPE OF SERVICE Rr:QUi:S rEo_ � 'T J j e Vic:/\/ <br />i n <br />COMMENTS: Nov 1 8 2008 <br />SAN ENVIRON COIJNTY <br />NEgCi4 DFA ENTAL <br />ACCE?7 EUkiY.— <br />/J <br />fJ� <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED 10:-- <br />aj _ --�__ <br />EMPLOYEE Ii: <br />DATE. <br />1--- <br />Dale Service Completed (it already Completed): <br />-_ <br />SERVICE CODE: <br />P I E: z <br />Fee Amount: <br />'�J/s <br />Amount Paid <br />S ! (,-�3 <br />Payment Date <br />Payment Type <br />— <br />✓ Invoice # <br />Check # , h ?� g <br />Received By: <br />EHU 43-02-020 <br />REVISED . „17;'2:'73 <br />SR FORM (Golden Rod) <br />