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SAN JOAQL -OUNTY ENVIRONMENTAL HEAL" , DEPARTMENT' t ' SERVICE REQUEST I Type of Business or-Property FACILITY ID# SERVICE REQUEST# S oo34 IRs S; �N gk OWNER I OPERATOR rr l CHECK if BILLING ADDRESS❑ FACILITY NAME 1 ,n.\ F!2 s l SITE ADDRESS l I"� �^ I( 3 15 l�)/� r 2; o ►2 c� J 7-oc 1< v�- j5 z 6 s Street Number Direction reet Name Cit ZipCode HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# Ll I PHONE#2 EXT. BOS DISTRICTLOCATION CODE ( ) CONTRACTOR It SERVICE REQUESTOR REQUESTOR WA_YNE ��lS�� CHECK if BILLING ADORE ` BUSINESS NAMEPHONE# EXT. 1—C; S qYL/- HOME or MAILING ADDRESS FAX# 5-Z-7 ,ti- (01) qq y 17 3 CITY F;Z<s,-lo STATE ZIP 9.3,2 Z BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HFALTII DrPARTMI:NI'Hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes,Standfirds,STATE and Fr-DERAI. wss.. �a APPLICANT'S SIGNATURE: DATE: lf�- -y— I'ROI-FItTY/BUSINESS OwNr.R❑ OPERATOR/NIANACER ❑ OTllfItAUTIIORizF.nAGENT'Rl ��'= •C� / Ec./� Ir.I PPLIC'ANT is not the BILLING PAR'T'Y proof of authorization to sign is required Title AU'1I10121ZATI0N 'r0 RELEASE. INr012MA'I'ION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DI:PAIZTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: U PAYMENT COMMENTS: C ti5�3 a l AUG 12 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPROVED BY: G EMPLOYEE#: 22 Z DATE: ASSIGNED TO: EMPLOYEE#: --7 DATE: O Z 01 Date Service Com leted (if al ady completed): SERVICE CODE: i PIE: ,�•3 0 9 Fee Amount: G Amount Paid c - Payment Date r �j Payment Type + Invoice# Check# Received By: EHD 48-01-025 SERVICE REQUEST FORM RFVI1-)I.1)G-5-0?