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SAN JOAQUIN COUNTY ENNRRONMF.NTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l { T-Z00t Lxoom�g <br /> OWNER I OPERATOR <br /> CHECK If BILLING AGGRESS <br /> FACRnY NAME /l/A I ib l Nall G1d (n(l e <br /> SITE ADDRESS 132-1 <br /> ` . I`I V L-oke St Lo cli, 8 524 <br /> at Number Dlredion S INemv ren I ZipCode <br /> HOME Or MAIr)qLING ADDRESS (If Different from Site Address) 115q q CoylCahnOn N VIA <br /> SDeet Number smNPI N.. <br /> City Liven--ore STATE CA ZIP q (-f'65o <br /> PHONE#I APN# LAND USE APPLICATION# <br /> (510) 200- LP3 -7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> c CHECK I{BILLIND ADDRESS <br /> BUSINESS NAME DeYW-51 n PRONE# I,Eei• <br /> �pl.lY1�Y , <br /> HOME Of MAILING ADDRESS FAx# <br /> 115q Concannnn Ntxl I I I <br /> Cm i STATE CA <br /> ZIP ('1/!_C o <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMFNT hourly charges associated with this project <br /> or activity will be billed to me or my business as idenfified on this form. <br /> 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 /> COLNTY Ordinance Codes,Standards,STATE and FED L laws. .,�/ <br /> APPLICANT'S SIGNATURE: N�{ ,Z°s(/� ✓ DATE: d �I Z :T/QlQ <br /> PROPERTY I BUSINESS OWNER❑ OPERATO MANAGER ❑ OruER At THORIZED AGENT❑ <br /> #'APPLICANT is not the BILUNG PARTY.proof of authori,adon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: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 en%ironmentaVsite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMEVUL HEALTti DEPARTMENT as Soon as it Is m actable and at the Sante FAM <br /> AmtUU��uAT <br /> provided to me or my representative. �pD <br /> TYPE OF SERVILE REDDESTED: Oar^ <br /> COMMENTS: [L <br /> oAN IOA0UINL NTY <br /> ENVIRONMEN L <br /> grALTH DEPART ENI <br /> ACCEPTED BY: 'l EMPLOYEE D DATE: <br /> ASSIGNED TO: .2a,I.N1j2 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: V <br /> Fee Amount: IS Z Amount Paid S Z — Payment Date L <br /> Payment Type ��LJ Invoice# ek# Received By: <br /> EHD 4842-025 S/t3 l Y SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />