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SAN JOAQUIN&UN'I'Y LNVIKONML,N'rAL HEAL'1 kA'AR'17VILN'1' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />&C- <br />F,+6006 773 <br />.5/ 00 32 3 Z-9 <br />C> <br />ASSIGNED TO: EMPLOYEE #: 8 2 1 '7 <br />FAX # <br />(20c1) <br />I l- 3 2 <br />OWNER/ OPERATOR <br />STATE C r, <br />CHECK If BILLING ADDRESS <br />co <br />Amount Paid a <br />FACILITY NAME (YV� P m o <br />% O <br />Payment Type ✓ <br />SITE ADDRESS ' 2 <br />Y`-� <br />I <br />CC'\ ` Or 71 <br />I <br />�L�j�l 1 <br />s� o y <br />Street Number <br />Dlredlon <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />LI <br />IQ-e—C\ii e C` P of i-\ �- C. p (. <br />C. (- C -D <br />Street Number <br />Street Name <br />CITY �'C P 1 <br />STATE � C1 ZIP Ci OL <br />• G� <br />vl G <br />PHONE #1 EXT. <br />APN N <br />LAND USE APPLICATION A <br />QC'q ) C1 ti - )-69y <br />PHPNE ##2 6 EXT. <br />3 . <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RRQUESTOR <br />REQUESTOR —"e -C' r-\; <br />CHECK IfBILLING ADDRESS <br />BUSINESS NAMEPHONE# <br />Q.— 0 C- c_A� r-6 I <br />T Y-\ <br />opt) <br />EXT. <br />%33 � <br />HOME Or MAILING ADDRESS <br />ASSIGNED TO: EMPLOYEE #: 8 2 1 '7 <br />FAX # <br />(20c1) <br />I l- 3 2 <br />CITY S\ O C <br />STATE C r, <br />ZIP 9`S-2 O S- <br />1311AANG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMLNTAL I-IBALTII DCPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on this folm. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Yee DATES: 1 - - 0 2 <br />PROPERTY / BusiNms OWNER OPERATOR / MANAGER ❑ OTHEit AUTHORt'LED AGENT e U L -Q— <br />If AP/'UCANT is not the BILLING PART!: proof of authorization to .riga is required Title <br />AUTI-IORIZATION 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 JOAQUIN COUNTY INVIRONML•NTAL 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 - <br />COMMENTS: COMMENTS: <br />e <br />APPROVED BY: <br />OYEE #: <br />DATE: <br />ASSIGNED TO: EMPLOYEE #: 8 2 1 '7 <br />DATE: 1 o3tJ <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: 30�' <br />Fee Amount: OHO ''DO <br />Amount Paid a <br />Payment Dale <br />% O <br />Payment Type ✓ <br />Invoice # <br />Check #D <br />Received By: <br />EHD 48.01-025 <br />REVISED 6.5-02 <br />SERVICE REQUEST FORM <br />