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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11 <br /> OWNER/OPERATOR c/o <br /> HECK If BILLING ADDRESS S i cv)z, <br /> �^P QC r-•^r .I'1/Jt&1') r C <br /> -mac r COW tr2LIL7-IC .J i r•,c.. <br /> FACILITY NAME s N �.f PQOPt:-1<-ry <br /> SITE ADDRESS S'O Z 0E- E 1 G HT MILE 2a. j;-To C Acro-J <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ErlA\tA arz• 51E• A <br /> Street Number Street Name <br /> CITY InCDE O STATE C 1D, ZIP 9S3S4 <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (Zal ) 5"3,f- 404o Ofty - oho - lo PA _ Iy.oOZW <br /> PHONE ICI EaT. BOIS DISTRICOT LOCATI01 CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR *cpl; IOD <br /> ACO CHECK If BILLING ADDRESS <br /> BUSINESS NAME LWC <br /> O_�K t7'tUfJ./V lll:d N✓�'IEM-/�L PHONE# EXT. <br /> Z�4 3to9• 03�5- <br /> HOME or MAILING ADDRESSFAX# <br /> sFo } w, OAK- ST . (v°t) 3t1o9 o3a� <br /> CITY L-0b ( STATE Gh ZIP 415,2 40 <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 DEPARTNIENT hourly charges associated with this project <br /> or 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 that the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standards STATE Bann d�F�EDp ] ss/ Q 2 <br /> APPLICANT'S SIGNATUREQ4& ,e u AFED I DATE: J 1 I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 13 <br /> If APPLLCANT is nod the BILL/NG PARTY proof of authorization 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 environmentaVsite 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: A•EV1LrW SOIL_ fOITAB11-17Y 1NITA A'TC t.o ADINb S' LDy �Q A, <br /> COMMENTS: (7/�-/ ��� IV <br /> l <br /> SAN.0 2 1S <br /> HE FlyyAOU/N <br /> Acry,0MFN 0 <br /> AgrM Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I ) SG'Z sS ' EMPLOYEEM DATE:-73)- IS <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P 1 E: .Z(Oo Z <br /> Fee Amount: Amount P (oSO,0(� Payment Date <br /> Payment Type Invoice# Check# 012-- Rec6ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod)/ <br />