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Jun.09.2010 10:32 AM KMNEb <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DLPARTMEN'UUN 1 8 2010 <br /> SERVICE REQUEST <br /> Type of Busirim or Property FAC <br /> OWMER I Opr=RATOR <br /> `� f� �9tactt Li WYEL CHH-rxnQ?5!NoAaor:ees� <br /> FAGRIIY NAME q �C <br /> HOME or WmNo ADDREss (If Different from Site Addrem) <br /> sUse!kuma,ar � <br /> CITY S-rArr <br /> ZIP <br /> PitQrE t - <br /> JAPN# L&w ttsE APPLWAT1QH# <br /> l 2 tt-- Ott) r.v <br /> Exr. Bt35 DI>irtilCT _,. LOCATION GODS <br /> NTRAMIR/9ERVICE REQUFST+QR <br /> R Uesm <br /> 41 CHECX If�XQ nRMM1 <br /> StJtSglES6 N;A11V EXT <br /> Ca <br /> H .J�AILit�U DOR!V�� FAX# l G <br /> (� 1t) $FATE( ZIP <br /> 1, the undersignod property or business owmr,operator or authorized agent or*,tole, <br /> acknowledge that all site and/or project specific ENvlRoNmENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be Filled to me or sty bu*iress as identified on this forni. <br /> I also certify that I have prepared ibis application and that the work to be performed will be dune in wtordanev with all SAN JOAQUIN <br /> COUNTY Urdfnrxnce C'aafes,Strrn[fa a-a rE and FaDx Z.la <br /> APPLICANT'S SICNATIJIREt c-JC9, <br /> r I)etTls: <br /> FrtO UTV/BUSINESSOWN8a0 OPkOATrott/MANAG,LR� OT1aagAtltnvar�soAcexT❑ — <br /> {f'AFPLI ANT IS not rhe fi,�„I „, miYof arattkodzafiy#k)si8m is req imd Title <br /> l4VIHORIZATLON TO RELEASE INEQ111WATIQN:Whet,applicable, I,the owner or operator of the Property located at the <br /> above; site uddreear, hereby authorize the release of any and all results, geotechnical data andlnr environmental/site assessment <br /> ini°Wnatioll to the SAN JOAQUIN CtWNTY 13NVIRONMEN'1'AL 11I!AL'i'I1.D:rARTMEN,1 as soon as it is available and at Ibe,,5alne tinm it is <br /> provided to me or my repro.-serltative. <br /> I'YAE OF SERVICE REQUESTED: k � '� �� �+-fl� fi i,T- <br /> so <br /> co,aleraI4-ca <br /> y REQ <br /> 1VEb <br /> 15 2010 <br /> ACCEPTED BY: 5� /4A <br /> \j+i=i EMPLOYttB ( � writ, D gT N7y <br /> AssIONED m EwLoYtE tP Cv°Z't7 DATE! 1' 0 New � <br /> E]aaa S*►rvlos Camp101ed (i[alreadtr ) SEWOU CODE <br /> Fog Amount X 3 4�`.t./Cl Amount Pald �`S 5 PSYment lt)slta (p 4 S � � <br /> PaynsentTYPO L� Involoe N Chock 9Received E9y; � <br /> EHr.D 4a-M-M <br /> �� <br /> �hVISED 11117120()3 SR FORMA(Golden%d) <br /> r <br />