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SAN JOAQUIN (T JNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2�S/Dn/T/A L 5 X00 3 3 8S(::, <br /> OWNER I OPERATOR u ,r ,,// <br /> I-A)Q9 SHA)e&W 11VA («-Q CHECK If BILLING AODRESS� <br /> FACILITY NAME <br /> SITE ADDRESS w ET�/�r=V�kley <br /> Steel Number Direction Street Name // Cit Zi Code. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1130 G u r CCF Street Number Street Name <br /> CITY 'FR ACV STATE ZIP Q <br /> CA ( 53 0 <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> c ) a(f 8—(Zo-02 A/07- /.06tcD <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> G CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> GF-�,� ConlSuc-T<N ��i8�/ 03 <br /> HOME or MAILING ADDRESS FAx# <br /> O • ( ) k S-Z5-f <br /> CITY 2 LO STATE CA ZIP 8 <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 HrALTI-I DEPARTMENT hourly charges associated with this project of <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT 1 d FEDettn ,i s. /� <br /> APPLICANT'S SIGNATURE: Al.:D <br /> IlKoPEIITY/BO51NESs OWNER❑ OPERATOR/MANAGER ❑ OTI It AUTHORIZED AGF.NT9 <br /> If'APPLICANT is Nor the IJILLING PARTY proof of authorizfirion to sign is required Titre <br /> AUTHOR17ATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located al 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 /> at <br /> TYPE OF SERVICE REQUESTED: „•OO1 L a�l.[�ri9-/.�l G /T PAYMENT - <br /> COMMENTS: <br /> MAY 16.2003 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRCNi4FNTAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: DATE: S—•{6_03 <br /> ASSIGNED TO: �, (�2�7 ES EMPLOYEE#: f DATE: 5—f&—03 <br /> Dale Service'Completed (if already completed): SERVICE CODE: LZ PIE: a4 6/ <br /> Fee Amount: 1� 00 Amount Paid / B oo Payment Date S—/(o-0 <br /> Payment Type 1/ Invoice# Check# '72-z Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5-02 <br />