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SAN JOAQU.0 ORNTY ENVIRONMENTAL HEAL'l� �EPAR'Fl4IEN7' SERVICE REQUEST �r Type of Business or Property FACILI71D# ' SERVICE REQUEST# 0Q6)3--�� OWNER/OPERATOR L6ERC; YE�-�� CHECK If BILLING ADDRESS FACILrrYNAME Lam„ VIi.,E'fAFZD C-{RFU" SITE ADDRESS �'j77% Ef1.t- uF,6f_-'Y w.<•:n0 GP,._4 9S Street Number Direction Street NameCit ZIp Cod. HOME or MAILING ADDRESS (If Different from Site Address) Street Number Slreel Name CITY STATE ZIP /yam PHONE#t EXT. APN# LAND USE APPLICATION# / (ats) 2S4-- C,77 cox - loo-oz O Lf —IOa(ms PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR WAL'TE-9, . G V�.}-1' CHECK If BILLING ADDRESSY_I BUSINESS NAME �` PHONE# ExT. Ln5 SFS' -4-1��~ HOME or MAILING ADDRESS FAX# 4l$ f�lA�tE�^t PLAZA CITY LCDI BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEAL-l1 DEPARTMENT hourly charges associated with this project or 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �'r &el DATE: t!2�/14z0 3 PROPERTY/BusINr.ss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® C-{Y« E N<;1 FSI E E-1 /fAYPL/CANT is 1101 the BILLING PARTY proof of authorization to sign is required CE 11584 Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the 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 informatiotl to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI'I DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: RLvl6l�/ �' S.utiF/�C£ pt:O vV�`Sta{�FJ°tC'Z`, CAfvTA1� l' ��T y ¢COMMENTS: ^ '� �j C 1 uc �plj� 1✓ I OCT 14 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S-f ENVIRONMENTAL HEALTH DIVISION APPROVED BY: EMPLOYEEM DATE: /� /Cr t `� Li ASSIGNED TO: i ll�r EMPLOYEE#: 36`.6 DATE: ( e J Cate Service Completed (if already completed): SERVICE CODE: 5 PIE: a Fee Amount: Amount Paid Payment Date Payment Type _ Invoice# Check# _i' Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02