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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> `. SERVICE REQUEST r, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A R,cuLTURRL �s o N% SOC 301 4 <br /> OWNER/OPERATOR rA/ <br /> �— RLL r2/'�J/it/ CO,yIP µ/ fI2 RMO �� CHECK if BILLING ADDRESS <br /> FAcu m NAME <br /> 5A�F <br /> SITE ADDRESS vV 70ANT Ll N£ 7—RAC- ( 9s 301 <br /> 17r �'45 Street Number I Direction Street Name C ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5/�/✓I Street Number Stmt Nam <br /> CRY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> I ) �?o PA - oa - a <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ c,•,,`rr^" " <br /> REQUESTOR <br /> BUSINESS NAME C- E Si6J E /ION S LU L T N <br /> HOME Or MAILING ADDRESo K G 1(/ <br /> hJ nVG ,GI�J !/`^�- 1µµµl///"''rr""" !Y'v✓,� <br /> CITY Q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned I <br /> acknowledge that all site and/or project specific ENVIRONMET r <br /> activity will be billed to me or my business as identified on d �il v" C <br /> ---^��is application and that t 'L/• - <br /> dw <br /> A,ST#lg and FED <br /> 41 <br /> RE <br /> OPERATOR/ A proof <br /> cGER1 / <br /> 1,-,. the BlLG/NG P.teT'}:pproof o r �' 1e,4r/W <br /> ,SE INFORMATION: W J <br /> Drize the release of any a �� Y'" t <br /> intomiaoo.. _ ;ouNTY ENVIRONMENTAL F. / <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: So/L S a 17-4-a <br /> COMMENTS: T <br /> 2�f/�7.etr�v112.r1 <br /> 3a - <br /> APPROVED BY: 1 <br /> ASSIGNED TO: <br /> Date Service Completed (if already completed): -• � ��, <br /> Fee Amount: I '� Amount Paid Payment Date <br /> Payment Type _ Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br /> 6���dy <br />