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JAN JOAQUIN UOUNTYENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> PoSEA Sllt ErrlPGE <br /> C) <br /> OWNER <br /> OWNER//OPERATOR <br /> •/ R BEr�/ f lQf./G{ CHECK If BILLING ADDRESS <br /> FACILfrY NAME <br /> 4,4Qze,<O W .eA SA N/6 TRAif <br /> SITE ADDRESS //71ro WEI' r CGO✓ElZ ROAD TRACY <br /> Sheet Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> o f AlI E /24 vmi Street Number Street Name <br /> CITY STATE ZIP <br /> CA S o <br /> PHONE#1 ExT- APN# LAND USE APPLICATION# <br /> 639 212 -260 - py PA - 06 - 630 Cs� <br /> PHONE#2Ear BOS DISTRICT LOCA777111C.pppJNgCODE <br /> ( ) - -5 / <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> DOA! 4'1(ESNE CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> C E n/E COnlSuori/✓� 2u �/ <br /> HOME or MAILING ADDRESS FAX# <br /> . O. OaK 3714 <br /> c 2ov > G 6 S-ZS9 <br /> CITY "rk 2 1-0 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standardsnd F laws. <br /> a e_i�l— <br /> APPLICANT'S SIGNATURE: DATE: 3 - ,21- (27 <br /> PROPERTY/BUSINESS OWNER OPERATOR MANAGER ❑ OTHER ADTHORIZED AGENT <br /> I,f�APPLICANT is not the BILLING PARTY proof o uthorization to sign is required Title <br /> AUTHORIZATION 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 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: eXPEDI TED REVIEW: 'Y177ZA TE LOAO <br /> COMMENTS: VILCEIVEb <br /> RUSHRQ <br /> ENVIRONMENTAL DEPART <br /> MFNr <br /> ACCEPTED BY: OL [if E r 44 EMPLOYEE#: ��? / DATE: 3 -C /G. <br /> ASSIGNED TO: —14 S:, G✓'10 C ( -0 EMPLOYEE#: L(c' C( s DATE: 3 ->--ec 7 <br /> Data Service Completed (if already completed): SERVICE CODE.: ys cZr PIE: q .017 <br /> C 2 <br /> Fee Amount:I_(JSw I - jlz.so Amount Paid 1a 5 Payment Date 3121101 <br /> Payment Type Invoice# Check# b 1 3 Received By: � r <br /> EHD 48-02-025 sk't"t7 'fvt(aoiden'Rod) ` <br /> REVISED 11/17/2003 <br />