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Sep. 30. 2015 3:02PM San Joaquin County No. 1371 P. 1-- """'be' <br /> SEP 2 3 2015 <br /> SAN JOAQUIr, COUNTY ENVIRONMENTAL HEALTh.,.$EPARTM ENT <br /> SERVICE REQUEST ENVIRONMEWAL.HEALTH <br /> k ES <br /> Type of Business or Property pAGILtTY ID# SERYiGE REQU31 w <br /> LOW <br /> 'dWNERIOPERATON CHSCK If O LtINt9 ADbRES9❑ <br /> :ova <br /> FAGLHY NAME � �y A p •-4 p�a aN, f J - ��/ (� -�,i <br /> $I'fEl#DDRE88 <br /> SneetNumber Direction C es(N e <br /> HOME of MAILINBADDRESS tit Different from Site Addrim) a� N i✓1 e7� <br /> $kreek Numbea 3froet Name <br /> CITY zip, <br /> PHOHE01 W APNif�I LAND USEAPT'I cAnoH# <br /> t v C1- °jV1(Q q' + '2 t�ezb <br /> p140IM92 Mm BOSDt$TRICT LOCAnoNCODE <br /> t ! <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR } n <br /> J� G1ir:CeeifgWa oAD,paEsc <br /> suelNEss NAsr>` # <br /> •Elite C OV11 1` W L7if 3-6 AL <br /> HOME or MAILING ADDRE FAx <br /> 01 <br /> C(TY ,TATE ZIP <br /> BILLING AC1{N LEDGEMENT: 1, the undersigned property or business o6/!rimer, operator or amhorized agent of same, <br /> acknowledge that all site and/or project specific ENVIltO ENTAL HEALTtt DIVARWRTZ'hourly charges associated with this project <br /> or activity will be billed to me of my business as identified on this form. <br /> 1 also cerafy diet 1 have prepared this application and that the work to be performed will be done in accordance with all SAH JOAQUIN <br /> COU14T'4'Ordinance Codes,Standards,STAT$ d FSIDE&kL <br /> APPLICANT'S SIGNATURE: DAT.: <br /> rrtOr:nTY/RVSYNM0WxM13 xoA/MAN'A(;rtt ® UTHBAADTItORkA NNT f/l Gni ( lam <br /> If.4PPLXANT is not rhe.81LLlNO PARTY proof of authorfzatfon to sign is required Trete <br /> A!UMRIZATI®N TO RELEASE INI.ORMATION:When applicable,1,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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY RNYIltONMENTAL 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: _9kz/ , 9�4e PAYMIEW <br /> COMNEttr6: FMENED <br /> 7'4'JSEP°2 3 Z41) <br /> SAN JOAQW4 COUNTY <br /> ENVItROMgN1 AL <br /> HEALTK DEPARTMENT <br /> AcciipwoBY: <br /> EMPLOYEE#: ,ld DATE: ea� x— <br /> A6SIGNFDTO: DATE:I -: <br /> Datio Service Completed (if already completed): URwcE CODE: _36W PIE: 40/V,97 <br /> Fee Amount:. . N,,_ , Amount Paid �r��� Payment Date <br /> Payment Type invoice it Gheck# 6D ReceivedBy:t6 <br /> EHD 48.02-M SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />