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<br /> AI�� OAQ�l1f1�sOCINTY`�N1%IRONMENTAL HEALTH DEPARTMENT
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<br /> E ��ICE EQUEST'
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<br /> Type of Business or Property ��"'�,,-�-'�,�"��",",",',,",',�`�,`,'�i,,`�," 11 lIll��-l j�I 17.II I I,I I,,I�,,�. FAGII iTY ID# SERVICE REQUEST#
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<br /> OWNER i OPERATOR 1 1 �"
<br /> /' CHECK if BILLING ADDRESS ,
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<br /> PfONE#1 EXT ARN# L4N_11D USE APPLICATION#
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<br /> PHONE#2 Exr ` BOS DISTRICT LOCATION CODE
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<br /> r y REQUESTOR�,� 1,111.1
<br /> s. -" �a 'C M '� px x," ; s `s' CHECK If BILLING ADDItES� ; ;,-
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<br /> BUSINESS IIVAIVE ��' h ; �,., Niik y EXT
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<br /> I>fON1E of MAIC ING ADDRESS x
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<br /> Bti_LING I'll -�l, LEOGE(V E T` t he undersigned, property or business°owner,"`operator or authorized agent of same <,
<br /> ackno led a Elia gall site a d/or, pro eci s ecific'ENVIRONMENTAL HEALTH uDEPARTMENT hOUf) :.Ch`a'r` eS aSSOClated Wlth46thrs o ect or
<br /> ac lu f be btl ed�to m"e Firm business as,tdenttfi, on this forri y g ; P 'j x 7
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<br /> .g.�F.""rz a ,�t,� F�"s�^�RiSh •`sy„y,*�`.'� r t_n"'' x''sr,,,.,..� t "'�Y ,.
<br /> also qce,,It, that l have ptepared;thls a pileabon artd thaf the work o be perFormetl will be tlone,in accordance with all SAN JoAouIN
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<br /> 11�1111 ,Ordlolnance Codes Sa»dartls $TA anAMM,d FEDERAL laws
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<br /> PROPERTYIBUSINESSOWNER,Q N OPERATOR/ ER ❑ OTHERAUTHORIZEDAGENT �' L yr
<br /> t* 11 ADPL CANT/S Of fhe B/CLINGxP4RTY proof Of a!!tl)Omc;!on t0 S/gn fS reLgUlred tt[e ` 11
<br /> RUTH©RlZATtQi�t T RE[.EASE;IfFQE2 hen sapphcabie, I, the owner or operator of the property located'at the akioue
<br /> site addressheeb`'eufhorize tFie reieaseof ani/and.al[results"` eoteahricai`data and/or`environmental%site assessmeri`t'i"forma"tion
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<br /> to the$ANloAQtiwCouNTvENVIrYONnnENTAL HEaLTti DEPARTMENT as soon as It Is available and at the same time It Is`provided to me ori
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<br /> my representative
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<br /> TYPE OFSERVICE REQUESTED
<br /> COMMENT$ �w , ° x �w�. i
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<br /> ACCEPTED BY EMPLOYEE#: DATE:
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<br /> ASSIGNEDTO EMPLOYEE : I DATE:
<br /> Date Seivice Competed (if already completed) SERVICE CODE: P/E
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<br /> Fee Amount Amount maid PaymentDate
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<br /> Payment Type 11 1� 'lnvoice# Check# 11 IReceived By:
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<br /> EHD 48-02-0-
<br /> 25 SI I R FORM(Golden Rod)
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<br /> 07/17/08 `! ,, .
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