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SAN JOAQUIN )UN7'Y ENVIRONMENTAL HEAL'I� _PAR'1'MEN'1' SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST 11 Pizo,00sEL) c o oL /� � /'oo3yc7y OWNER/OPERATOR CHECK It BILLING ADDRESS E C614,El4al%lef T FACILITY NAME CNoco o GS SITE ADDRESS /-1/yyWAY lye CrL-EM 6NT5 9Sa�7 IOngli Street Number Dim ifon Sir eIN e CII zip Ca e HOME Or MAILING ADDRESS (11 Different from Site Address) 37 Noa.r/ Wtl-GOK VVAY Street Name Cm STOC�CTON STATE ZIP S Z f L PHONE#1 EXT' APN 0 LAND USE APPLICATION N ( ) 131 -5( ev 101?- 2+0:10 ,44.46o PA - oa a 28 PHONE N2 ExT. SOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Do tl ^Pg 7`ac CHECK If BILLING ADDRESS BUSINESS NAME (' PHONEM EZT. C N E n/ o HOME Or MAILING ADDRESS FAX N P. O . FOX 3-7414- ( ) 660- 7-510 CITY L O L STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with [his projector 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,Standards,SATE and FE • laws. APPLICANT'S SIGNATURE: DATE: I Z Z –O 3 PROPUrrY/BUSINESS OWNI-,R❑ OPRRATOR/ ANAGRR ❑ Ti1ER AuTitoiuzED AGENT GV If APPUCAHT-is flat lite BILLING PARTY.proof of out oriZali0//!o sign it required Titre AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, Inc 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 t0 file SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is rovided to me or my representative. TYPE OF SERVICE REQUESTED: A//T!z A 7—c L a AD L ulrA014/III 57u 0r EoW V1 EW IyY,////,, 1 _ t o f i COMMENTS: �y 5 }�)4r13 RFrte ;=1\/�-(� JAN 2 2 2003 ,iv "Ar A r ni ry ' �'�' I APPROVED BY: `- EMPLOYEE#: �� DATE: —Z.;7-'-If? ASSIGNED TO: jlA EMPLOYEE#: Q� DATE: —7„ '3--03 Date Service Complet d (if already completed): SERICECODE: 5 PIE: Fee Amount: �Lj Amount Paid �1j�5 Payment Date 1 Payment Type j �' ` invoiceit Check# - Received By: //"�� c. C t__ EHD e0-01-025 - SERVICE REQUEST FORM REVISED 6-5-02