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` AU /07/2008/THU 03; 13 PM � �• P. 003 <br /> SAN JOAQUIN COUNTY EN-WRONMENT.AL HEALTH UEPAR'TM1;N•T <br /> SERVICE REQUEST <br /> Type of Business or Property ' FACILITY ID# SERVICE REQUEST# <br /> . . . .. . . . . <br /> OWNER/OPERATOR ;� � LL� <br /> CHECK if <br /> FACILITY NAME / � S 44 4 <br /> SITEADDRESS / gAM <br /> rrat Number Street Na /G o' <br /> HOME or MAILINQ ADDRE5$ (If Different from Site Address) <br /> Street Nu o <br /> CITY STATE ZIP <br /> PHONE 91 Exr, APN 11 LAND USE APPLICATION# <br /> 6616 ) SS�a ®0 <br /> PH Nf 5>7� �i I� EXT(`e 1 E<05 DISTRICT /A LOCATION C E <br /> ( NI/D '71 ( I N <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ! ' <br /> L CHECK if BILLING ADDRESS <br /> BUSINESS NAME ` t PH h EXT* <br /> / � D <br /> HOME O MAILING ADDRE � 40 t1 <br /> CITY STATE �� ZIP �1'5 lS,:�, �Q <br /> BILLING ACKNOWLEDGEMENT, I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENyiRoNwNTAT-HEAi-TH DEFAATt ENT hourly charges associated with this project <br /> or activity will be billed to me or my business Iden'fed on this form. <br /> I also certify that I have prepared this ap cation aid hat the work to erfonn i11 be nc in accordance with all SAN JOAQUIN <br /> CovNTY Ordinance Codes,Standards, T and ERAL laws. , 4 r <br /> APPLICANT'S SIGNATURE: DATLO: r <br /> PROPERTY/BUSINESS OWN4111' OPERA,TOIt ANAUNR ❑ OTmw AUTI;rORIZED AGENT❑ <br /> IfAPPLICANT is not the•BILLING PAItTX.proof of authorization to sign is required Vitt e <br /> AUTHORIZATIONTO RELEASE INFORMATION: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, geotecWca) data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL MALTH DEPARTMTNT as soon as it is available and at there time It isprovided to me or ray representative. � <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: AUG 1 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> t4EALTH DEPARTMENT <br /> AGCEPTRP I3Y: C EMPLOYEE : DATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 1, /E: V 2 <br /> Pee Amount: Amount Paid b IGb payment nate g <br /> Payment Type v ` •invoice# CMec" Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br />