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10 / 08 / ZU1U U8 : 44 AM t''AA -LUIDOZD1U44 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FOWNER <br /> Of B (uefness or Property FACILITY ID # <br /> SERVIC1 RIOU1ST #I OPERATOR ,r <br /> 06 i CHI LIN D pg, <br /> FACILITY NAME <br /> o lMQ <br /> SITEAo0REss / /nlEr <br /> r K �Ji �, - 1/GlV'�, ( <br /> HOME or MAILING ADDRESS (if Different from Site Address) ! tro a <br /> r e <br /> CITY StreotNu bar et <br /> $TAE IP <br /> PH Ns #i ;/ r el �7* <br /> APIN S LANDmm" 9e APP 1nq <br /> PHOI 92 I I exr. <br /> ( ) 6103 DI j o / LOCATION CQDE <br /> L <br /> COIVTRACTO / S R'VICE QUES OR <br /> kFG1UESTpR <br /> KYR. tm`ve �1AIII V N M +'[ 4 I n N (I I /l CHECK IIA LINOrl IIADq�F ,53D <br /> 13USINess NAMEPlV�1 ' /5 /� } /� <br /> ) � ' ' � J 1 1 U Y t V L 4 n l Vl � : NE # .� 1 Ext . <br /> F <br /> HOME or MAILING ADDRESS l FAxY7 <br /> r <br /> TY $TATE , ZIP GIS 6,11 <br /> B LI G A KN WL E ENT: I , the undersi ed pr erty oruslnees owner, operator or authorized agent of game , <br /> acknowledge that all site and/or project specific ENVIRO ENT L HEALT DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on t rm , <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 JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATURE: <br /> ill � , .y` . k <4 DATE1 <br /> PROPERTY I BUSINESS OWNER IS OPERATOR I MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT IS not the BILLING PAR, proof of authorization to sign Is required vile <br /> AUTHORIZAT{ N TO RgLEASE INFORMATION ; When applicable, i , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is provided to me or <br /> my representative . <br /> NEI RFCPF 1 VE "D <br /> TYPE OP SERVICE ItQUESTED; <br /> COMM@NTS ; <br /> OCT 10 2001 <br /> ENNARON1INIENTAL 1IEALTII <br /> 1) EPA WI' NI ENT <br /> =ASSIGNED <br /> EMPLOYEE #: DATEI <br /> EMPLOYEE #: DATE <br /> Data 5e1`1/10e Completed (it already comploWdV SERVICE CODE: P 1 C <br /> Fee Amount: Amount Paid Payment hate <br /> Payment Typa Invoice # Check # Received By : <br /> E,HD 48.02%026 SR FORM (Golden Rod) <br /> 07117108 <br />