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i <br /> SAN JOAQUIN tCOT. L' ENN IRONNIENTAL HEA-Th DEPARTMENT <br /> ;SERVIt:E REQUEST <br /> Type of Business or Property ^,=,CIL ITY u# SERVICE REQUEST# — <br /> Svqw 5 -)Q2 <br /> OWNER/OPERATOR �_ 1 CHECK if BILLING ADDRESSO <br /> FACILITY NAMFr-- — <br /> /r7 �� l-c �v- v <CE- <br /> SITE <br /> - <br /> SITE ADDRESS --{— �— <br /> 1 ru c 5 3 <br /> Street Number Direction � `��S l reet NamC� Zi Code <br /> HOME or MAILING ADDRESS (if Different rolCrt Site Address) A tS <br /> i c�111 /T' <br /> _ ,r}JS�(/� Street Number � Street Name <br /> C! SATE ZIP <br /> _ C14D <br /> PHONE#1 WN LAND USE APPLICATION# <br /> 00 ) 94`4 -5 - 3/0 _aU /?,-,, &Cj( 145 -e ' <br /> PHONE#2 EXT. BOS DISTRICT -\ LOCATION CODE <br /> ! ) 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ACDRESS i_1' <br /> BUSINESS NAME PHONE# E, <br /> _ I <br /> HOME or MAILING ADDRESS FAX# <br /> I <br /> CITY STATE ( 1 ?IP �I <br /> 3'LLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator G ii ized agent of <br /> fi�;:uJwleuYe that all site and/or project SpcCifiC ENVIRONMENTAL HL'ALTi-i DEPARTMENT hourly charg ssociated with this <br /> c2'activity will be billed to me or my business as identified on this form. <br /> !sc erti y that ! have prepared this application and that the wor!<tc be performed will be dere in accc nce wi±" a!! <br /> t Jrdinancc Codes.Standards. STAT a <br /> id FEDERAL laws. <br /> 1 / <br /> A-'PLJCANFISSIGNATURE: AD11E: Y- <br /> Ot-d,ia i I,a i;65 0WNc.R� OPERAaTOii i (`ri.+.�:ii::LR <br /> df APPLICANT is not the BiLt_LvG PARTT,prop) of authorizedon to Sign IS required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property locaietl iiie <br /> abcve site address, hereby authorize the release of any and all results, geotechnical data and,'cr environmental/site <br /> information to tkC SAN JOAOUIN COUNTY ENV1RONMFN'I'AI HF.ALTa DEPARTMENT as soon as it is available and at the same tine ;t <br /> pi ided to Ine or my representative. <br /> 3r rvicE fREGUEiTcDAlf <br /> ----- �U _ -- – -PAYM1" <br /> RECEIVED, <br /> APR 14 2009 <br /> SAN JOAQUIN COUNT`/ <br /> ENVIRONMENTAL <br /> I-1EA1TH DrP ATTt/lEm: <br /> ASSIGNEC I'0: — EMPLOYEE DAT -— — -- <br /> -FeenY.o i CER`/;CSr.CC.. �• 7, c-,- <br /> Fee <br /> Amount: Amount Paid 1 O Pat Gate 1 C <br /> r <br /> ayment Type invoice# Check# Q — Received I By: <br /> EHD 48-02-025 SR FORM(Golder.Rod' <br /> RE'vISED 11/17;2003 <br />