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0 <br /> 000734 0 <br /> 000493 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPARTMENT <br /> SERVICE REQUEST <br /> Typo:of Business or Property FACILITY ID# SERVICE REQUEST# <br /> iafj j= � ..� t <br /> OWNER I OPERATOR <br /> CHECK If ElILLING ADORES <br /> FACILITYNAME L01 MemcrW 0 aSpl+6L( <br /> SITE ADDRESS 1-115 r-(Y) + <br /> Street c Number Dir 023 rest Na e i Co <br /> HOME or MAILING ADDRESS Jif Different from Site Address) <br /> Street Number <br /> CITY STATE ZIP <br /> P 0N,g� FXT• APN# LAND USE APPLICATION# , <br /> Lo 10,5 <br /> PHONE#2 EXT. BOSDISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR liana, N t ✓4e) <br /> CHECKifAUW2ADRME3 <br /> BUSINESS NAMEW e-s I err Pw.yLp I I n e-• P ONE# 5-7rt 1_7_1ExT. <br /> NOME or MAILING ADDRESSC3t_ `. F �j 7 t •C� <br /> re1TY &n D i o T STATE c ice. 6 �zip Ct 2110�Z— <br /> BILLING ACgIOWLFDGEMENT: 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 or <br /> activity will be billed to me or my business as identified on this fornT. <br /> I also certify that l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St dards,STATE au ' - L Laws.�� <br /> APPLICANT'S SIGNATURE-,, DATE: <br /> PROPERTYIBUSINESS OWNER❑ OPERATOR/ FR ® OTHER AUTHORIZEDAGI:NT1A I�frtr!Ian �� <br /> IfAPPL1CANT1s not theB1LLINGPARTY,proefofarttitorization to sign is required Title <br /> ACITI QMATION 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 environmental/site, assessment <br /> information to the SAN J0AQ01N COUNTN'ENVIRONMENTAL IlEALT11 DEPARTMENT as Soon os it is available and at the some time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: t t _ %r - .�� I r` RECEIVED <br /> COMMENTS: <br /> S`�"��� f-anK. DEC 13 2007 <br /> SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY C. I E�:�.� EMPLOYEE#: C, DATE: > <�1 <br /> ASSIGNED TO: t :, f S EMPLOYEE#: (6� DATE: I L._ f j }" <br /> Date Service Completed if already completed): SERVICECOOE: (r:' "j� PIE: <br /> Fee Amount: Y 7 ,t";�I/ Amount Paid 1 .__. Payment Date % <br /> Invoice# Check# Received By: <br /> Payment Type �� 1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />