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FROM' "� ✓� " �® FAX NO. 'ay. 15 2009 01:02PM P2 <br />MAY 1 5 2009 SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br />ENVIRONMENT HEALTH SERVICE REQUEST <br />PfAMJg0@ ffiperty • <br />Re -mal.( uV1%As <br />C <br />FACILITY ID tl�SERVICE <br />FA00©49-m <br />REQUEST# <br />s 3z <br />OWNER/OPERATOR <br />WW <br />Vbv <br />11p 13 <br />qex- <br />I�•�•C"HtVKifB1LLINolA�DDRess <br />Cd• �•J` <br />FAciLRYNAEE F+a-'^cLyaykxce <br />cxmevv% <br />SAN JOAQUIN COUNTY <br />SITE ADDRESS <br />n <br />516 <br />HOPE or MAtUNG ADDRESS Dr Dmerem from <br />she Address) <br />bb Wt Nuinew <br />v,w, Name <br />r�` <br />/ <br />CIIITTY/�EC�%tT]^[c- 61ir1�.. <br />STATE /'+ /� 21e 9537 <br />Pr <br />L <br />`/V ('1 V 3 9- 53 V �� <br />EMPWYEE#: <br />A°N /.AND V%E`APrr}L••IG�4TIDN 71 <br />DATE: <br />[b '39-7-7er,. <br />SOS DISTRICT <br />Ln TIDN CDDE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTDR CH KifAWdaADD MII <br />BUSINESS NAME <br />HOME or MwtwG ADDRESS /4y 0, <br />amt —r'� '.r ( <br />ZIP <br />BILLING ACKN LV—iMDGEMEA C: 1, the Undersigned property or business owner, operator or authorized agent of some, <br />acknowledge that alt site and/or project specific ENvtRO tL I-ILALTIi i7FPART.kfLVrhourly charges assoxiiatui with this project <br />or activity will be billed to me to my siness as idevl - this otm. <br />I also certify that I have prepared thi, lication and th Tic to be pert w' be dome m acawdancc with all SAN JOAQM <br />COUNTY Or&nance Coles, SYancl(trd STATE and • . S. <br />APPLICANT'SSIGNFATURE: DATE:-.. JY.•I��©q <br />PROMTY / WRIA--mss 01,W-NMMMC] . .PR OTNrn ArrraD AGerrr O i <br />ffAP t/eq,vT is nor the Bmijm, P,IRTr. prDef of 4N1horiZa inn to sJgt ' regnired Title <br />ATI7FIORIZATION TO EFLEASE ENFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the felease of any and all results, geotechnical data and/or cnvironmenta)/sit, assessment <br />information to the SAN Jo.oQt nN CDt,,Nry LNvTRONMEVrAL HEAI,TTI DEPARTNE T as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REODESTED: <br />C <br />E� C (' \ / F G <br />Ir <br />CDNNF?f7S: <br />(%61& <br />MAY 1 5 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DFPARTMENT <br />ACCE TED BY: <br />EWWYE£R: <br />DATE: <br />AsaIGNEDTp: <br />EMPWYEE#: <br />/ <br />DATE: <br />Date Service Com Cdalresdycotnpleted): <br />SaeltcECDDE: Z7, PIE: <br />-4M <br />, <br />Fee Amount <br />Amount paid <br />fol O <br />Payment Date s <br />Payment Type Czv- <br />Invoice if <br />Check# <br />Received By. <br />END 46-42-025 �. w�(1f-YN I;— <br />REVISED iv172om SR FORM (Golden Rod) <br />