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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Ensiness or Property FACILITY ID# SERVICE REQUEST# <br /> SR0030J b <br /> OWNERI OfERATOR <br /> wti CHECK if BILLING ADDRESS 0 <br /> I , . 1 U A Q <br /> FACILITY NAME6C,) ( OI�'� <br /> j'kq DREg. T7«+ y7 /s.._�' '�p✓l ��jZotr <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME Or AILING ADDRESS (If Different from Site A dress) <br /> O l �/(�.M a�'1 Street Number Street Name <br /> CITY STATE ZIP <br /> 1 410 cA g sZo-S <br /> PHONE#1 Exr' APN# I-11 -2:1;,> 02 LAND USE APPLICATION# <br /> a-0� ) SGS- (,LSD I t 1 --LI -o <br /> PHONER E r. BIDS DISTRICT LOCATION CODE <br /> l�) �•�! -'S 1'LYS <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /}1LMNti D�( <br /> CHECK If BILLING ADDRESS <br /> /�'v PHW)x, BUSINESS NAME A - l_Ow�t �� P �) �6S^�� <br /> ' HOME or MAILING ADDRESS FAx# <br /> I q 0 iL,) . Fa�-' ( 24:$-4 U66 213 -1 <br /> CITY rW Gam_.., I STATE ZIP �Q 2 <br /> BILLING ACKNOWLEDGEMENT: I, the un -Fa u. I it authorized agent of same, <br /> acknowledge that all site and/or project specific E7 (�cv +w�^�° �u t " " s associated with this project or <br /> activity will be billed to me or my business as ides S-c O 30 t ',L� Sia <br /> add.-ess - ND Ks ef�Le <br /> I also certify that I have prepared this application :ordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes Standards STATE and '?[4/"Z- <br /> APPLICANT'S <br /> ?[4/"Z <br /> (_i S 0. r.�a-cat �i 0 uc c <br /> �( APPLICANT'S SIGNATURE: <br /> �(t mac[ (S 4 K w F ei( fo C F c o f - �-L <br /> / PROPERTY/BUSINESS OWNEPM OPERATOR/ <br /> [f APPLICANT is not the BILLING PA. Title <br /> AUTHORIZATION TO RELEASE INFORMt 0 of the property located at the <br /> above site address, hereby authorize the relew environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENviRc dable and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 459 PAYMENT <br /> RECEIVED <br /> JUL 12 2002 <br /> l {� SAN JOAQUIN COUNTY f�(�t <br /> APPROVED BY: ona ` K EMPL##: <br /> L t[ EN IWE#MEN�F V'`•'L�I (� <br /> ASSIGNED TO: EMPLb DATE:Date Service Completed (if already completed): CODE: IS PIE: <br /> Fee Amount: -)8 Amount Paid ? ,�f- Payment Date X <br /> Payment Type 1 j Invoice# Check# l2Z)�, Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 5-5.02 <br />