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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property S�(�U <br /> OW NER I OPERATOR R c fj 0A _ fA►eM%S CHECK if BaJJNQ AOpRESsItL <br /> FAcam NAIVE (L 3 yv\ V i f.J E J A 9-t,S <br /> SDEADOREss <br /> Ilelzl E LIBERpY ptUtt^�Po �15� zo <br /> J�(_sS }sae.tNmw.r <br /> HOME or MAILING ADDRESS (If Different from SKe Address) <br /> Name <br /> Cm (LIPorJ -- STATE GA LP 9S3loly <br /> PHONE#1 �' APN# LAND USE APPLICADON# <br /> (�1) S99 - J 18(v con-tFD -03 r -o`E <br /> PHONE tf2 <br /> Ex. SOS DISTatOT LDeATION cooE <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR M391 (ZP -C c o CNSCK1f BItiR+o A[N7RGS4❑ <br /> on. <br /> BusiNEss NAME LWE ONS GEOENJtR-O+�1 rt1E t�'r p`L- P� # 1i9-03�T <br /> FAX# <br /> HouFor MAN.INGADDRESS tJ • dprv- ST. (209) 9' 03�'�• <br /> STATE GN I LP 4T 2--+C> <br /> Cm L•ovl <br /> 8U T JlSG ACKNOWLEDGEWNT: L the undersigned property or business owner, operators or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONMEWALHE.ALTH DEPARTMENT hourly charghs associated with this project or <br /> activity will be billed to me ormybusiness as identified on this fog. <br /> I also certify that I have prepared this application and that the work to be performed will be dote in albcordanoe with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand r STATE and 1 FEDERAL laws. <br /> APPLICANT SSIGNAT �\ \`NI � DAze: <br /> PRDTEaTY/BOSINES4OWNER� OPERATOR/MANAGER0 OTRIia A trrstoRtzP.D Aca.'r�T TUtr <br /> !f APPLICANT Lr not the BILLING P.LeTI:Proof of authorization to sign is required <br /> AUTHOlro ATION TO REr EASE UR DEMATION:when applicable,I, the owner or operatdr of the property located at the <br /> above site address, hCreby authorize the release of any and all results, geotechnical data and/or envirtnmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avFilable ynd at the same tum it is <br /> provided to rnq or fny representative. v <br /> TYPE OF SERVICE REQUESTED: (ZEVIE-vJ SVR-Y PuGG Y Ss)F(ZVRt if CE LOtrTAt'l 1 JJiarTTOnJ t"'-1✓PDRT <br /> Comma": �-:5 r 1 / RECEIVED <br /> f �tat7/zi /r3� 3 DEC 3 1 .2010 <br /> •N.,�: -z'01�C SAN�OAOUIN COUNTY <br /> ENONMENT <br /> TH DEPARTMENT <br /> ENMLOYEE#: (� DATE: I Z. '-3 <br /> ACCEPTED BY: (� <br /> �p ' EMPLOYEE#: ! DATE: <br /> ASaIGNEr)TO: �/��t ��C.6. i <br /> yt�eACEcaee PJE:2� O <br /> Date Service Completed (H already completed), � <br /> Foe Anooant 2 Amount Paid Payment Data 2 3 ! ( 0 <br /> Payment Type i/ <br /> Invoice# Check# 3( J `"� S Received By. <br /> SR FORM(Golden Rod) <br /> Gran dA_M_tYlS <br />