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;;7-" NAN JOAQIJIN COUNTYENVIROlvMEiNiAL <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property --�- O <br /> CHECK if BILLING <br /> OWNER I OPERATOR <br /> FACUTY NAME <br /> SITE ADDRESS /�(,��� N `�(� q L I Ci t zi <br /> F <br /> Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Name <br /> Street Number <br /> STATE zip <br /> CITY <br /> P Ext. APN# <br /> LAND USE APPLICATION# <br /> PHONE#1 <br /> Exr. <br /> J1830S DISTRIICT r- <br /> PHONE#2 � •r..`. <br /> CONTRACTOR/ SERVIC; _ .�I ,g _ fG � <br /> rorW <br /> "C81W L7 Xo <br /> '4-4-0 <br /> I ��6•�f �,�ry� k <br /> 46W <br /> i3 <br /> Crry <br /> ��-y � • ! uperty or but � /o�i S � <br /> acicnowlet �`'f-� r� O! lln k L HEALTH DE <br /> + � -ff� orm <br /> activity w f � N <br /> �,� � 't! be erfi /4��� r <br /> ! �ork to p 3 ��►) <br /> I also cel c ��� _LDza <br /> � 5. <br /> CouNAPPLIC <br /> TY� <br /> f�l U JA,r f OTHER AUTHORI2,ED AGYN"r❑ <br /> PROPER ! Title <br /> � . ^ ' i authorization to sign is required <br /> RUTH l V�� hen applicable,I, the owner or operator of the property located at the <br /> I Ind all results, geotechnical data and/or.environmental/site assessment <br /> above . F <br /> o HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> information <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> L-i q0d M <br /> COMMENTS: <br /> AUG 2 7 2007 <br /> SAN SaAOUIN COUNTY <br /> ENVIRONMENTAL <br /> (b HEALTH DEPARTMENT <br /> ACCEPTED BI-7 a7 EMPLOYEE#: D� DATE: Qom'_Z70 <br /> Y: d' lJ <br /> EMPLOYEE#: 5 ` DATE: g—Z T Q <br /> ASSIGNED TO: <br /> 4SERVICE CODE: PIE: <br /> Date Service Completed (if already completed): " <br /> Fee Amount: 119 0� Amount Paid Payment 1 , Date <br /> ( <br /> Payment Type <br /> Invoice# Check# (� Received By: . <br /> �`Std FQRN►(G7olderi Rod) ' <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />