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Jan-31-08 08:44 0 0 P.02 <br /> SAN JOAQIIIN COUNTY ENVIRONW N'1'Al,HEA1,111 DEPARTMENT <br /> SERVICE, REQUEST <br /> Type of Business or Property v FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /&,,4'G,-,�- , CHECK If BIDING ADDRESS D <br /> FACILITY NAME <br /> SITE ADORESS <br /> /�, <br /> 42Street Number I DI—41--1Street City ZID Code <br /> HOME of MAILINo ADDRESS (If Different from Site Address) / V-5- 1 <br /> j <br /> „-, Street Number /�� -$treat Name <br /> CITY STATE ZIP <br /> PHONE ill EAT. APN# LAND USE APPLICATION# <br /> (z09► 96 _��/t� <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR ! SERVICE REQ UESTOR _ <br /> REQUESTOR l�J <br /> a) 1', yv 11 r v, l Y CHECK if BILLING ADDRt:3S <br /> BUSINESS NAME PHONt II ExT. <br /> ACS 1nj R s+e 2 rv ) 'us /l <br /> HOME or MAILING ADDRESS 0) O FAX# 1119 <br /> f (ati <br /> , <br /> CITY ` Y\Q 6 6v Q 2 -- ZIP TT- <br /> BILLING ACKNOWLEDGEMENT- 1, the undersigned property or business owner, operator or authorized agent of sante, <br /> acknowledge that all site and/or project specific ENVIR0NMI-.N'IA1.HNAI 1-11 r)EPAIktMJ;N r hourly charges associated with this project ur <br /> activity will be billed to me or my husiness as ideutiCcd on this form. <br /> T also certiiy that I have prepared this application and that the work to be performed will be dune in accordance with all SAN JOAt)1.lIN <br /> C01INTY Ordinanc-c Codes,.Srrrnrlurdc, �and 1'LSl)IiNAI, laws, <br /> Al')PLICAN'[''S STGNAT[1RL:, --_� �� � Ow� � � 02 11 <br /> NRQI'ENTY/BI1RINFSS OWNER❑ OPERATOR/MANAGER� OTnrm AC1Y11JItP/.l:D ACRNT❑ <br /> If it/rl'LICANT is rlut!/u:l�ll.l.lNfi P�IHLi,proof of uuthari7.ntion to Sigel is required— Title <br /> AT71101T%ATION TO RELEASE. TN1,01tMA1'10N: Arhen applicable, 1, the owner car operator of the property located at the <br /> above site address, hereby auThot'i7e the release of any and all rrsults, geotechnical data and or cnvironmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY UNVIRt)NWNTAI HEALTH DEPARTMENT as Suun as it is available and at the same tinge it is <br /> provided to me or my rep reset da live. '( <br /> TYPE OF SERVICE REQUESTED:— <br /> COMMENTS: <br /> vN� <br /> SPN N`l�0 p-QpSN <br /> ACCEPTED BY: L EMPLOYEE#: >' DATE: <br /> ASSIGNED TO; i EMPLOYEE#: `z6�� DATE: <br /> Date Sorvice Completed (if alroady Completed): SERVICE CODE: PI E: <br /> Foo Amount: ,r'` Amount Paid 1 gC O Payment Date 2/�(0 8- <br /> Payment Type Invoice# Check#�l – Received By: <br /> EHD 48-02-025 3,R FORM(Golden Ftod) <br /> REVISED 11/17/2003 <br />