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SANJOAQU1srCOUNTY ENVIRONMENTAL HEALTH,�.4PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 60-5 'S}0. i d 18S "s"O&/2 £8 e <br /> OWNER OPERATOR . <br /> Circ"ie. 1{ S.L.TVreS 10 ,n CHECK if BILLING ADDRESS <br /> FAauryNAN <br /> { <br /> 164'o La.rr.br i c{ e S'r- L.afhro p 95330 <br /> Sheat Winteri n �15tr N <br /> — City 2210 code <br /> HDPE or Nllutum ADDRESS (If Different from Site Address) <br /> 4'15 <br /> /� Er Recon 51i #1 So <br /> `tQ S I Street NumMr <br /> clC-ofUn& sTaCA ZIP 9287 <br /> PHONE#1 En. APN# LAND USEAPPLICATION# <br /> (q5) ) Z7(.) 514-4 <br /> PHONEO2T EDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILDNO ADDRESS <br /> BuSINr�ss NA E PHONE# EZT' <br /> S lwvt fro e T'n Lim 1 q2-3 7 <br /> HOME or MMuNo ADDRESS FAA# <br /> O 5VL- Go),, (go 923 CIS7Z <br /> CIVI J—r v i11 STATE C� ZIPS <br /> q2-3 <br /> 9-S <br /> I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <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: ,Ie� DATE: 10— 14— Ih <br /> PROPERTY/BUSINESS OWNERO OPERATOE/MANAGartO OTiomAumoRIZEDAGENT AnC_r`k <br /> IfAPPLJCANT is not the BILLRVG axis.proof ofouthortzadonto sign itmqulmd Title <br /> AUTHORIZATION TO 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, geotechnical data and/or environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQNESTED: N 441J/¢[ D <br /> COMMENTS: <br /> RECEIVED <br /> OCT 19 28.10 SGT 1 8 2010 <br /> sM JOAQUIN COuNTM E14VIRUNMENT NEALT <br /> DEPATMEfITwpliniPERMIT SERV <br /> ACCEPTED BY: OLl t/E7 ,.� �I EMPLOYEE#: 0 J DATE. L© I IV <br /> As51GNEDTO: .--/—,D I�F�T EMPLOYEE#: 2& DATE: Q L <br /> Date Service Completed (If already completed): SERnaE CODE: / b P ?—Tv', <br /> Fee Amount J�, �, ,�� ; Amount Paid _ Payment Date kg <br /> ( Go <br /> Payment Type Invoice# Cheek# 1 Z n Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />