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11/20/2003 11: 55 4640138 ENVIRONMENTAL I-IFALTH PAGE 02 <br /> SAN JOAQUINWOUNTY ENVIRONMENTAL$EALl""ARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property S 60 3/_ / <br /> OWNER/OPERATOR e CHECK if BtILf LLMO ADDRESS❑ <br /> Q lJ nIh <br /> FACILITY NAME I <br /> SITE ADDRESS 1 A , �a n ` L` I \ C _ oL ��p ZI Co <br /> 5 0 `�'' S Name CI <br /> Sheet Number r etioo <br /> DOME or MAILING ADDRESS (H Different from Site Address) <br /> Sheet Number el Na <br /> STATE ,ZIP <br /> CITY <br /> PHONE#1r APN# LAND USR APPLICATION# <br /> (ALA) A I - 898( 101 I (J-0 OC TION CO <br /> PHONE 11211 <br /> En BOS DISTRICT LOCATION COPE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR !�_1_� CHaCK If ESTEEM: DDR <br /> A <br /> `/ 7` PHONE# E� <br /> BUSINESS NAME -t-ho <br /> Vy1 Q <br /> 1tFAx# <br /> FI5a7 - 9dy5 <br /> HOME Or MAILING ADDRESS )y <br /> T <br /> 5T 7E ZIP CJ 3.5 y <br /> CITY <br /> BILLING ACTINO EDGEMENT- 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 projector <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 that the work to be performed will be done in ordance with all SAN JOAQUIN <br /> AOLNTY Ordinance Codes,Standards,STATE and FEDERA laws. <br /> PPLICANT'S SIGNATURE: / DAT'' ?�17 0 <br /> PROPERTY/BMIAy <br /> ]BUSINESS OWN£RD OPERATOR/ <br /> AGE �HER AUTHORIZED AGENT <br /> �` proof <br /> f f Titre <br /> JrAPPLIGNT is not the B/J,J./IY PARTY. rd0 o autharilalion to sign 15 required <br /> ATTMORIZATI N TO RELE E ORMATION: Whcn 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 /> infeimation to the SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn a4 It is available and at the same time it is <br /> ll provided to me or my representative. 1 d <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �f <br /> RECEIVED �f <br /> •/ s U r ((� LN,NOV J2 0 2003 <br /> � � R SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: <br /> ASSIGNED T EMPLOYEE#: (9 DATE: <br /> Date Service Co -eta l ( already plated): SERVICE CODE: f PIE: ' 0 <br /> Fee Amount: Amount paid �i — Payment Date c f9 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 45-02.025 SR FORM IGWck$I n Rod) <br /> REVWED 11M7P=3 <br />