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08/09/2004 15: 30 4b4013ti LNViKUNMLN I FAL I-ftAI-11-1 t'Hut Ui <br /> ` SAN JOAQUIN '- AUNTY ENN'1RONMENTAL HEALTF'VPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &A-S S-1-4 f7crti! C,C, y y�. <br /> OWNER/ OPERATOR <br /> 51-) bUCS CG)r4St P/c U(7u c, S L CHECK if BILLING ADDRESS <br /> FAC1LnY NAME <br /> 4r2CC, <br /> SITE ADDRESSJ . P I�2 SOLI PASS f bA 'D TF?aC �/ q53-77 <br /> 7 7 5 Street Number Dlrectlon Street Name city Zipode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> St of Number Stre <br /> CITY STATE ZIP <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, SOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESSIJ- <br /> P. <br /> PHONE!# EttT' <br /> BUSINESSNAME_ t5y5 i7 ]Irtj� <br /> 1 V i f2 C lel f l - E-t j FAX# <br /> HOME or MAILING ADDRESS <br /> NCbJLL� Sii2��1 ( •71,F ) GAS" -000(c- <br /> STATE (7 Zip '—iZ Y'� `_'3 <br /> CfrY �I� )�l �- 14 <br /> BILLING ACIC WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent same, <br /> acknowledge that all site and/or project Specific ENVTR.ONMENTAL HEALTT-T DEFARTMENT hourly charges associated with this prT oject or. <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /-. rI k,f'L� DATE: /Z-3 SOS"- <br /> PROPERTY/BUSINUSOWNER❑ Or ATOR/MANAGER ❑ OTHER AUTtmRIZEDAGENT <br /> � P`Z <br /> (% <br /> ��proof f Tft,a <br /> Tf APPLICANT is'not the BILLING PAR1Y roo o authorization to sign is required <br /> ted at the <br /> A THOR,IZATION TO RELEASE INFORMATT011: When applicable, Ieotechnical datapan.d/or envuonmeerator of the ntaUsite erty assessment <br /> above site address, hereby authorize the release of any and all results, g <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 7 FI LL Jr 1/4/-1 ,5C�--nl5�. �� P- L C`C I t VE ��r Z(--,?�C. I <br /> COMMENTS: C.CS.r y=1~•�-lj F r l <br /> �� 4 �pp5 <br /> PQV�N T P� <br /> SP�Nv�RONM�R MENS <br /> EMPLOYEE#: L' 3 z I ATE: orf IGS <br /> ACCEPTED BY: C�L-(C �( �-� / <br /> EMPLOYEE M 7.3 A>-C DATE: <br /> ASSIGNED TO: S H 1 1-I <br /> Date Service Completed (if already completed): �j/23 �C'rj <br /> SERVICE CODE: ,•1� k; PIE: �s �,�� <br /> Fee Amount: N, '��/• C'C �7 <br /> Amount Paid — Payment Date a <br /> P Type y Invoice# <br /> Check# Q3 eceived 6y: <br /> SR FORM (Golden Rod) <br /> EHD 48-02-025 <br />