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r <br /> SERVICE REQUEST ...r <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AG P I r—U LTU RAL— APt�t ; o o(_ 230-39 <br /> OWNER OPERATOR 7H-,MA5 5. A t4b SANDRA (oh- S—ro kE 5 BILLING PARTY❑ <br /> FACILITY NAME JA1 l� AS ovcttERIQPERATa1Z PjBov oti sro <br /> KES F>giZh'l5 <br /> SrrEADDRESS 7581 WE—= KI LE RO�-,Z� t-L D 1/ C A ')5242 <br /> S4.H Nambr DPectien StrM Name TYpA SuNaa <br /> Mailing Address (If Different from Site Address) <br /> SAME. AS G171= A!b➢R.E55 <br /> CITY LORI STATE !A LP <br /> PNOHE#t Fnr. APN# O©1 - 2 -3C) LAND USE APPLICATION# <br /> (20cf -79¢— 2515 <br /> PHONE92 En. BOS DISTRICT - LOGUION 000E <br /> za9 4�3- 3r°4 5 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR WBUM PARTY <br /> )5,' <br /> L� c <br /> R c . uR�L 5 )5,' <br /> BUSWESS NAME Cl.k{L �♦3�IIV��� PHONE# rar. <br /> 20 3<,S—fit Is <br /> MAILING ADDRESS Al S M A.�� P t_ ZA FAX# <br /> Cm LOo( STATE CA ZIP 9524-o <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DmSION houdy charges associated with this project or activity will be billed to me or my business as identified on thls form. <br /> I also cartlfy that I have prepared this application and that the work to be Performed will he done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �/n'/ <br /> APPLICANT SIGNATURE: LhJN�- <br /> �,./ DATE: / <br /> PROPERTY/BUSINESS OWNEJr ❑ OPERATOR/MANAGER 70. QTHERAUTHOWIED AGENT Q C I y 1 L_ t t.LG I KA e�I-: <br /> IrAaM'Jwr is nor rhe poolo/authodradon to sign is reguirad CT=WtlEiS4' Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,[,the owner or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnicat data and/or environmentatsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EWRONMENTAL HEALTH DNISION as soon <br /> as it is available and at the same time it is Provided to me or my representative. <br /> TYPE OF SERVICE REQUEST ED: �h15VR.FAG'E c " <br /> AµD Sug,,uE7-FACE c©r,C[ANI1FlrlTtOµ REFrSZT jZEY1aW <br /> COMMENTS: <br /> Rc�.aTt�vlE�Ft PSG CEO <br /> Oaf laJc>3 f'evleL'3 P-¢pN ENNpONMNENEa��°uc>o" <br /> 30 v-r,mv4tao u <br /> INSPECTOR'S SIGNATOR : CONTRACTOR'S SIGN T�OIRrE: <br /> APPROVED BY:. f Z EMPLOYEE#: � DATE: <br /> -ASSIGNEDTO: �1—r1 6�. EMPLOYEEM �r �1 DATE: <br /> Date Servico Completed (if alre completed): SERWCE CODE: .P 1 E:. 6C <br /> 7 <br /> Fee Amount: 1 Amount Paid Payment Date <br /> Payment Type Invoice#' Check# Received By: <br /> v <br />