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SAN JOAQUINE+1,VMONMENTAL REAL.w DEPA <br /> SERVICE REQUEST <br /> Type of Business or property FACILITY ID g SERVICE REQUEST# <br /> CcA-S Yrf -LO FA;000 4521 S200443 14 <br /> OWNER/OPERATOR C H90K If 81LLING ADDREss1 <br /> r <br /> FACILITY NAME <br /> SITE AD RESSZ 5 l J r'ILtVL�Q�GL. J 1 <br /> P Street Numbor ireetlen Stye c C Zip C04 <br /> HOME or MAILING ADDRESS of Different from site Address) <br /> street Number Street Na e '� <br /> Cfry STATE ZIP 6 <br /> PHONE E%Y• APN# LANp USE APPLICATION# <br /> e <br /> PHONE42 EXT. SOS DISTRICT LoeAnoN CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR CHECKif BILLINe AGDREss p <br /> ��e Sf4-4t y% SSMs B l�U e��t�t a�rxti : <br /> Btl Nr=r.s NAMEPHO �cT• <br /> Vt tc'" S S f'U S l 3— (Q V <br /> }'TOME or MAILING ADDRESS FAX( � �3 T c[J -lam a <br /> Gfrr L AOSL SPATE Q _ ZIP 9SJ dv <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business Owner,operator or authorized agc»t of same, <br /> acknowledge that all site and/or project specific ENvIRONtvzNl'AL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified oz1 this form. <br /> I also certify that I have prepared this application and that the wor%to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,,Standards,STATE and FEDERAL laws. } <br /> AI?PLICANT'SSIGNATURE: L'. 6�' 1,� -ti��s�'iv DATE: /��lC` Lµ <br /> PROT=RTY/BuSl�,`MOWNER❑ OPERA.TORIMANAGMt O•rnmAUTHoFxw �AGiUTr© (: rq [IQ.f-lC " <br /> #" APPLrCLvr is not the BILLNNG PA proof of authorization to sign is required Tart a '. <br /> AU I HORII�ATION TO RF,,LEASE INFOR1Vll,A,TION: When applicable,I,the owner or operator of the property located at the Iri <br /> above site address,hereby authorize the release of any and all results, geotechnical data and/or cnvironn>,ental/site assessment <br /> information to the SAN JOAQtmv COUNTY ErrvlRm sxTAL HEALTH DUARTmENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ` <br /> TYPE OF SERvicE REouESTED_ �5 T /�-�T/LDIC/T - ,a N <br /> COMMENTS: tY�`(ISN.{ T `� �LS �O�L✓(�yTT1 `� LSoi. WDa <br /> OCT 12 2005 <br /> SAN JOAQUIN COUNT <br /> ACCEPT®BY: ,t.L/ ( <br /> EMPLOYES* 032- 1 DATE:HEtZ pJP/@yE <br /> A591CiNEDT0: EMPLOYEE DATE: 10 !2-(0$ <br /> Date Service Completed (It already completed): SgW CE CODE: Ng P i E: 2-3109 <br /> Fee Amount- 79,00 AmountPald !�C� 011 Payment Dale 10112- 10,5 <br /> M <br /> Payment Type i/ Involce# Chock# '7 g Received By: 1— <br /> " <br /> r : <br /> EHD 48.02-025 SR FORM(Golden R <br /> REVISED 11117/2003 <br />